Healthcare Provider Details

I. General information

NPI: 1366998619
Provider Name (Legal Business Name): ALIREZA MOFID MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 07/08/2023
Certification Date: 07/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 E MICHIGAN AVE STE 300
LANSING MI
48912-1806
US

IV. Provider business mailing address

1140 E MICHIGAN AVE STE 300
LANSING MI
48912-1806
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-5200
  • Fax:
Mailing address:
  • Phone: 517-364-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2023
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number4301507973
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: