Healthcare Provider Details

I. General information

NPI: 1386186849
Provider Name (Legal Business Name): JABAR BUFKIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2016
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14145 TROESTER ST
DETROIT MI
48205-3541
US

IV. Provider business mailing address

14145 TROESTER ST
DETROIT MI
48205-3541
US

V. Phone/Fax

Practice location:
  • Phone: 313-598-8056
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberB125355379461
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: