Healthcare Provider Details

I. General information

NPI: 1942598990
Provider Name (Legal Business Name): MOHAMED MAHMOUD JABER M D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2011
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3990 JOHN R ST
DETROIT MI
48201-2018
US

IV. Provider business mailing address

4617 ALLEN RD
ALLEN PARK MI
48101-2765
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-5111
  • Fax: 313-745-3500
Mailing address:
  • Phone: 313-779-8113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberDR.0056088
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number4301098779
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4301098779
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301098779
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: