Healthcare Provider Details

I. General information

NPI: 1326262817
Provider Name (Legal Business Name): EMAD NAKKASH, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 08/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22039 JOHN R RD
HAZEL PARK MI
48030-1712
US

IV. Provider business mailing address

PO BOX 279
HAZEL PARK MI
48030-0279
US

V. Phone/Fax

Practice location:
  • Phone: 248-336-3937
  • Fax: 248-336-3938
Mailing address:
  • Phone: 248-336-3937
  • Fax: 248-336-3938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4301064463
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number4301064463
License Number StateMI

VIII. Authorized Official

Name: DR. EMAD NAKKASH
Title or Position: PRESIDENT
Credential: M.D
Phone: 248-336-3937