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General NPI Number Information
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NPI Number | 1013896638
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Entity Type | Organization
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Legal Business Name | BLUE WATER PRIMARY CARE
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Dates
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Enumeration Date | 08/28/2025
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Last Update Date | 01/28/2026
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Provider Practice Location Address
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Address Line | 3953 24TH AVE
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City | FORT GRATIOT
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State | MI
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Zip | 48059-4193
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Country | US
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Telephone | 734-299-0712
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Fax |
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Provider Business Mailing Address
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Address Line | 3953 24TH AVE
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City | FORT GRATIOT
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State | MI
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Zip | 48059-4193
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Country | US
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Telephone | 810-363-9337
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Fax |
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Authorized Official
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Title or Position | CHIEF OPERATING OFFICER
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Name | DR. IBRAHIM DABAJA
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Credential | PA-C, PH.D.
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Telephone | 810-363-9337
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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