Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2080P0203X | Pediatric Critical Care Doctor | 036.117289 | IL |
Y | 2080P0203X | Pediatric Critical Care Doctor | 4301502539 | MI |
NPI | 1083866107 |
---|---|
Provider Name | Mina Hafzalah |
First Address | Detroit, MI 48201-2153 |
Second Address | Detroit, MI 48201-2119 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/10/2008 |
Last Update Date | 14/08/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036.117289 | STATE LICENSE (01) | IL |
4301502539 | STATE LICENSE (01) | MI |
7548 | STATE LICENSE (01) | SD |