Provider Demographics
NPI:1679543425
Name:JBOOR, NIDAL J (MD)
Entity type:Individual
Prefix:
First Name:NIDAL
Middle Name:J
Last Name:JBOOR
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 1:25614 FORD RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-3024
Mailing Address - Country:US
Mailing Address - Phone:313-791-8000
Mailing Address - Fax:313-791-8002
Practice Address - Street 1:25614 FORD RD
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-3024
Practice Address - Country:US
Practice Address - Phone:313-791-8000
Practice Address - Fax:313-791-8002
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301082688207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4736485Medicaid
MI4736485Medicaid