Healthcare Provider Details

I. General information

NPI: 1104497395
Provider Name (Legal Business Name): WARDHA SHABBIR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2021
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N EAST AVE
JACKSON MI
49201-1753
US

IV. Provider business mailing address

26750 PROVIDENCE PKWY STE 210
NOVI MI
48374-1212
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-4800
  • Fax:
Mailing address:
  • Phone: 248-465-4469
  • Fax: 248-465-4503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number4301513354
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4351047565
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: