Healthcare Provider Details

I. General information

NPI: 1932107794
Provider Name (Legal Business Name): SHOLEH VAZIRI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 08/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6770 DIXIE HWY SUITE 200
CLARKSTON MI
48346-2087
US

IV. Provider business mailing address

6770 DIXIE HWY SUITE 200
CLARKSTON MI
48346-2087
US

V. Phone/Fax

Practice location:
  • Phone: 248-625-2621
  • Fax: 248-625-8938
Mailing address:
  • Phone: 248-625-2621
  • Fax: 248-625-8938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberSV071408
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: