Healthcare Provider Details

I. General information

NPI: 1386857357
Provider Name (Legal Business Name): MEHDI DJEKIDEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 01/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 OAKWOOD LN
HAMDEN CT
06518-1153
US

IV. Provider business mailing address

16 OAKWOOD LN
HAMDEN CT
06518-1153
US

V. Phone/Fax

Practice location:
  • Phone: 313-310-5356
  • Fax:
Mailing address:
  • Phone: 313-310-5356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number4301084044
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301084044
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number47906
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number47906
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: