Healthcare Provider Details

I. General information

NPI: 1205275161
Provider Name (Legal Business Name): MUSTAFA AL-SHAMMARI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2013
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

PO BOX 670884
DETROIT MI
48267-0884
US

V. Phone/Fax

Practice location:
  • Phone: 800-653-6568
  • Fax:
Mailing address:
  • Phone: 313-874-4806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number4301504577
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number17199
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberP29238
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: