Healthcare Provider Details

I. General information

NPI: 1619959772
Provider Name (Legal Business Name): KIANOUSH KHAGHANY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16151 19 MILE RD
CLINTON TWP MI
48038-1158
US

IV. Provider business mailing address

1 FORD PL STE 3A
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 586-263-2308
  • Fax:
Mailing address:
  • Phone: 313-874-4806
  • Fax: 734-457-4030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4301072919
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: