Healthcare Provider Details

I. General information

NPI: 1053763862
Provider Name (Legal Business Name): MOUNIR DJEMIL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2016
Last Update Date: 06/21/2024
Certification Date: 06/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BARCLAY AVE NE SUITE 300
GRAND RAPIDS MI
49503-2556
US

IV. Provider business mailing address

330 BARCLAY AVE NE SUITE 300
GRAND RAPIDS MI
49503-2556
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-8810
  • Fax:
Mailing address:
  • Phone: 616-391-8810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301110650
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: