Provider Demographics
NPI:1225779531
Name:SAMAD, MOMIN
Entity type:Individual
Prefix:
First Name:MOMIN
Middle Name:
Last Name:SAMAD
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2799 WEST GRAND BLVD., CFP 1
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202
Mailing Address - Country:US
Mailing Address - Phone:313-916-1888
Mailing Address - Fax:
Practice Address - Street 1:22250 PROVIDENCE DR.
Practice Address - Street 2:SUITE #301A
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4818
Practice Address - Country:US
Practice Address - Phone:248-849-3254
Practice Address - Fax:248-849-5449
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-02
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351049456207RG0100X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology