Basic Information
Provider Information | |||||||||
NPI: | 1083866107 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HAFZALAH | ||||||||
FirstName: | MINA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4201 ST. ANTOINE | ||||||||
Address2: | UHC 5D - MAILBOX 226 | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482012153 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3139665051 | ||||||||
FaxNumber: | 3139660665 | ||||||||
Practice Location | |||||||||
Address1: | 3901 BEAUBIEN ST | ||||||||
Address2: |   | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482012119 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3137455629 | ||||||||
FaxNumber: | 3139660105 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/21/2008 | ||||||||
LastUpdateDate: | 08/14/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/14/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0203X | 036.117289 | IL | N |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 2080P0203X | 4301502539 | MI | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
ID | Type | State | Issuer | Description | 4301502539 | 01 | MI | STATE LICENSE | OTHER | 7548 | 01 | SD | STATE LICENSE | OTHER | 036.117289 | 01 | IL | STATE LICENSE | OTHER |