Healthcare Provider Details

I. General information

NPI: 1861439788
Provider Name (Legal Business Name): SHAZIA WADOOD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 05/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12170 CONANT ST UNIT: C/2
DETROIT MI
48212
US

IV. Provider business mailing address

12170 CONANT ST STE C2
DETROIT MI
48212-4137
US

V. Phone/Fax

Practice location:
  • Phone: 586-604-8108
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301079852
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301079852
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: