1861693772 NPI number — DR. SOPHIA I MEHBOOB M.D.

Table of content: DR. SOPHIA I MEHBOOB M.D. (NPI 1861693772)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861693772 NPI number — DR. SOPHIA I MEHBOOB M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEHBOOB
Provider First Name:
SOPHIA
Provider Middle Name:
I
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861693772
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/31/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15511 REECK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHGATE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48195-2651
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-282-1117
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2799 W GRAND BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48202-2608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-916-4906
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/29/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  4301091877 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 5501010517 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: 4301091877 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)