Healthcare Provider Details

I. General information

NPI: 1861021297
Provider Name (Legal Business Name): IYA OWAINATI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2020
Last Update Date: 08/28/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3031 W GRAND BLVD STE 600
DETROIT MI
48202-3014
US

IV. Provider business mailing address

3031 W GRAND BLVD STE 600
DETROIT MI
48202-3014
US

V. Phone/Fax

Practice location:
  • Phone: 313-871-3751
  • Fax:
Mailing address:
  • Phone: 313-871-3751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301509661
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: