Provider Demographics
NPI:1447039235
Name:OWAID, IBTISAM
Entity type:Individual
Prefix:
First Name:IBTISAM
Middle Name:
Last Name:OWAID
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13840 W WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-1425
Mailing Address - Country:US
Mailing Address - Phone:313-846-8156
Mailing Address - Fax:
Practice Address - Street 1:13840 W WARREN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-1425
Practice Address - Country:US
Practice Address - Phone:313-846-8156
Practice Address - Fax:313-846-8569
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601012109207R00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine