Healthcare Provider Details

I. General information

NPI: 1265400477
Provider Name (Legal Business Name): MUHAMMAD AZRAK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18100 OAKWOOD BOULEVARD SUITE 205
DEARBORN MI
48124
US

IV. Provider business mailing address

26901 BEAUMONT BLVD STE 3D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 313-438-7880
  • Fax: 313-438-7882
Mailing address:
  • Phone: 947-522-1863
  • Fax: 947-522-0307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number4301069915
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301069915
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: