Provider Demographics
NPI:1861439358
Name:SOUBANI, AYMAN OMAR (MD)
Entity type:Individual
Prefix:
First Name:AYMAN
Middle Name:OMAR
Last Name:SOUBANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 E. MAPLE RD.
Mailing Address - Street 2:SUITE 400-CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1135
Mailing Address - Country:US
Mailing Address - Phone:800-527-6266
Mailing Address - Fax:313-576-8381
Practice Address - Street 1:4100 JOHN R ST
Practice Address - Street 2:KARMANOS CANCER CENTER
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2013
Practice Address - Country:US
Practice Address - Phone:800-527-6266
Practice Address - Fax:313-576-8381
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301075101207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P30630141Medicare PIN