Healthcare Provider Details

I. General information

NPI: 1932024205
Provider Name (Legal Business Name): MOHAMED ELAMIN OMER ABDALLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/22/2026
Certification Date: 08/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 SAINT ANTOINE ST # 5C
DETROIT MI
48201-2153
US

IV. Provider business mailing address

1760 KIRTS BLVD APT 108
TROY MI
48084-4342
US

V. Phone/Fax

Practice location:
  • Phone: 313-577-5092
  • Fax:
Mailing address:
  • Phone: 720-592-5717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number4351057182
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: