Healthcare Provider Details

I. General information

NPI: 1740701291
Provider Name (Legal Business Name): HAZAR H KHIDIR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2017
Last Update Date: 06/21/2026
Certification Date: 06/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 313-916-1545
  • Fax:
Mailing address:
  • Phone: 313-876-4806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number272686
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA198019
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301517570
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number69105
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: