Healthcare Provider Details

I. General information

NPI: 1285071100
Provider Name (Legal Business Name): IHSAN DJOMEHRI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2013
Last Update Date: 07/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 E MICHIGAN AVE
LANSING MI
48912-1811
US

IV. Provider business mailing address

1215 E MICHIGAN AVE
LANSING MI
48912-1811
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-2583
  • Fax:
Mailing address:
  • Phone: 517-364-2583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301103143
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: