Healthcare Provider Details

I. General information

NPI: 1699189456
Provider Name (Legal Business Name): FARIDEDDIN NOSSONI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2014
Last Update Date: 07/09/2022
Certification Date: 07/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19000 ST JOE'S PARKWAY SUITE 310
LIVONIA MI
48152
US

IV. Provider business mailing address

24 FRANK LLOYD WRIGHT DRIVE SUITE J2000
ANN ARBOR MI
48105
US

V. Phone/Fax

Practice location:
  • Phone: 810-494-6830
  • Fax: 810-494-6834
Mailing address:
  • Phone: 734-747-6766
  • Fax: 734-222-3100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number5101020975
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number5101020975
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: