Healthcare Provider Details

I. General information

NPI: 1932767795
Provider Name (Legal Business Name): MARYAM SAMIR YOUSIF MATLOUB
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2019
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3555 W 13 MILE RD STE N120
ROYAL OAK MI
48073-6710
US

IV. Provider business mailing address

26901 BEAUMONT BLVD STE 3D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 855-863-8761
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number4301508883
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number4301508883
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: