Provider Demographics
NPI:1861637811
Name:MAMOUN, IRFAN (MD)
Entity type:Individual
Prefix:
First Name:IRFAN
Middle Name:
Last Name:MAMOUN
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 1:22550 BARD AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-2907
Mailing Address - Country:US
Mailing Address - Phone:440-378-4186
Mailing Address - Fax:
Practice Address - Street 1:36175 HARPER AVE
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-3274
Practice Address - Country:US
Practice Address - Phone:586-741-3772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-04
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1416982085R0202X
MI43010385172085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301038517OtherMEDICAL LICENSE