Healthcare Provider Details

I. General information

NPI: 1205055464
Provider Name (Legal Business Name): FAREEHA NAZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 E MICHIGAN AVE
EAST LANSING MI
48912
US

IV. Provider business mailing address

2475 JULIE WAY
DEWITT MI
48820-7873
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-3700
  • Fax:
Mailing address:
  • Phone: 517-668-2475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301085998
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: