Healthcare Provider Details

I. General information

NPI: 1588651897
Provider Name (Legal Business Name): MUSTAFA SIRAJ BOHRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15120 MICHIGAN AVE
DEARBORN MI
48126-2916
US

IV. Provider business mailing address

6950 CARLYLE CROSSING
WEST BLOOMFIELD MI
48322-3082
US

V. Phone/Fax

Practice location:
  • Phone: 313-582-2142
  • Fax:
Mailing address:
  • Phone: 248-471-5469
  • Fax: 248-478-5307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number4301067914
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: