Healthcare Provider Details

I. General information

NPI: 1962024968
Provider Name (Legal Business Name): MOHAMMAD IBRAHIM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2020
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1022 N TELEGRAPH RD STE 2
DEARBORN MI
48128-1622
US

IV. Provider business mailing address

1022 N TELEGRAPH RD STE 2
DEARBORN MI
48128-1622
US

V. Phone/Fax

Practice location:
  • Phone: 313-764-0088
  • Fax: 313-254-3586
Mailing address:
  • Phone: 313-764-0088
  • Fax: 313-254-3586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number5101027367
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101027367
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: