Healthcare Provider Details

I. General information

NPI: 1134790009
Provider Name (Legal Business Name): MAZHED KHEYRBEK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2021
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22201 MOROSS RD STE 50
DETROIT MI
48236-2166
US

IV. Provider business mailing address

22201 MOROSS RD STE 50
DETROIT MI
48236-2166
US

V. Phone/Fax

Practice location:
  • Phone: 313-343-7774
  • Fax:
Mailing address:
  • Phone: 313-343-7774
  • Fax: 313-343-8747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number4301512361
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: