Provider Demographics
NPI:1588907299
Name:PERACHA-RIYAZ, MANAL (MD)
Entity type:Individual
Prefix:
First Name:MANAL
Middle Name:
Last Name:PERACHA-RIYAZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 N MONROE ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-2936
Mailing Address - Country:US
Mailing Address - Phone:734-242-2727
Mailing Address - Fax:734-242-2745
Practice Address - Street 1:725 N MONROE ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-2936
Practice Address - Country:US
Practice Address - Phone:734-242-2727
Practice Address - Fax:734-242-2745
Is Sole Proprietor?:No
Enumeration Date:2013-04-01
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0086473207W00000X
DCMD046531207W00000X
MI4301103242207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
14033965OtherCAQH