Healthcare Provider Details

I. General information

NPI: 1396951158
Provider Name (Legal Business Name): KAMEL MOSTAFA GHABEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: KAMEL MOSTAFA M.D.

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

1 FORD PL STE 3A
DETROIT MI
48202-3450
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 TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301501030
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberN9101
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number25MA09254700
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberMD448092
License Number StatePA
# 5
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number4301501030
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: