Healthcare Provider Details

I. General information

NPI: 1134568181
Provider Name (Legal Business Name): TAREQ ISMAIL MARAQA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2013
Last Update Date: 10/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HURLEY PLZ
FLINT MI
48503-5902
US

IV. Provider business mailing address

6348 LAURENTIAN CT
FLINT MI
48532-2039
US

V. Phone/Fax

Practice location:
  • Phone: 810-262-6023
  • Fax:
Mailing address:
  • Phone: 480-619-7081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number72018
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number4301112540
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number4061
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: