Healthcare Provider Details

I. General information

NPI: 1154610335
Provider Name (Legal Business Name): FARRAH HAFEEZ D.O
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2011
Last Update Date: 04/02/2021
Certification Date: 04/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80600 VAN DYKE RD
BRUCE TWP MI
48065-1333
US

IV. Provider business mailing address

80600 VAN DYKE RD
BRUCE TWP MI
48065-1333
US

V. Phone/Fax

Practice location:
  • Phone: 810-798-6560
  • Fax:
Mailing address:
  • Phone: 810-798-6560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101019545
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: