Healthcare Provider Details

I. General information

NPI: 1083078802
Provider Name (Legal Business Name): AMANDA ISMAIL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 03/10/2021
Certification Date: 03/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7001 ORCHARD LAKE RD STE 200
WEST BLOOMFIELD MI
48322-3606
US

IV. Provider business mailing address

6689 ORCHARD LAKE RD # 297
WEST BLOOMFIELD MI
48322-3404
US

V. Phone/Fax

Practice location:
  • Phone: 248-538-7400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number4301502871
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207WX0110X
TaxonomyPediatric Ophthalmology and Strabismus Specialist Physician Physician
License Number4301502871
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: