Healthcare Provider Details

I. General information

NPI: 1376521922
Provider Name (Legal Business Name): AHMAD KADDURAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 09/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HURLEY PLZ ATTN: PROFESSIONAL BILLING DEPT
FLINT MI
48503-5902
US

IV. Provider business mailing address

PO BOX 956
GRAND BLANC MI
48480-0956
US

V. Phone/Fax

Practice location:
  • Phone: 810-262-9353
  • Fax:
Mailing address:
  • Phone: 810-233-7103
  • Fax: 810-257-9710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number4301063683
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number4301063683
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: