Provider Demographics
NPI:1063725620
Name:MOHAMMAD DERANI MD PC
Entity type:Organization
Organization Name:MOHAMMAD DERANI MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:DERANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-581-0909
Mailing Address - Street 1:15401 W WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-1359
Mailing Address - Country:US
Mailing Address - Phone:313-581-0909
Mailing Address - Fax:313-581-3252
Practice Address - Street 1:15401 W WARREN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-1359
Practice Address - Country:US
Practice Address - Phone:313-581-0909
Practice Address - Fax:313-581-3252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-23
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301045768208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI190127-10Medicaid
MI0824892Medicare PIN
MI190127-10Medicaid