Basic Information
| Provider Information | |||||||||
| NPI: | 1689649923 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ABDULRAZZAK | ||||||||
| FirstName: | MAMDOUH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 GREENFIELD RD | ||||||||
| Address2: | |||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481264124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135633332 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4700 GREENFIELD RD | ||||||||
| Address2: | |||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481264124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139456100 | ||||||||
| FaxNumber: | 3139455260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 04/29/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RS0012X | 4301063026 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 2084N0400X | MA0163026 | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 4272199 | 05 | MI | MEDICAID | 5209224 | 05 | MI | MEDICAID |