Healthcare Provider Details

I. General information

NPI: 1376393645
Provider Name (Legal Business Name): AMMAR KHASRACHI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2024
Last Update Date: 03/27/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3353 DETROIT ST
DEARBORN MI
48124-4157
US

IV. Provider business mailing address

3353 DETROIT ST
DEARBORN MI
48124-4157
US

V. Phone/Fax

Practice location:
  • Phone: 218-790-7159
  • Fax:
Mailing address:
  • Phone: 218-790-7159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number2080P0205X
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: