Healthcare Provider Details

I. General information

NPI: 1275997447
Provider Name (Legal Business Name): LUBNA IQBAL FATIWALA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2016
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 SAINT ANTOINE ST # 2E
DETROIT MI
48201-2153
US

IV. Provider business mailing address

4201 SAINT ANTOINE ST STE 2E
DETROIT MI
48201-2153
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-4832
  • Fax:
Mailing address:
  • Phone: 313-745-4832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301500795
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: