Healthcare Provider Details

I. General information

NPI: 1245161918
Provider Name (Legal Business Name): MEHDI FOUAD DABAJA OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2026
Last Update Date: 05/29/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19329 MACK AVE
GROSSE POINTE WOODS MI
48236-2833
US

IV. Provider business mailing address

19329 MACK AVE
GROSSE POINTE WOODS MI
48236-2833
US

V. Phone/Fax

Practice location:
  • Phone: 313-428-2170
  • Fax:
Mailing address:
  • Phone: 313-428-2170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901005941
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: