Healthcare Provider Details

I. General information

NPI: 1043604135
Provider Name (Legal Business Name): MOHSIN MOHAMMAD REZA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2015
Last Update Date: 09/01/2023
Certification Date: 09/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2717 N TELEGRAPH RD
MONROE MI
48162-9217
US

IV. Provider business mailing address

2717 N TELEGRAPH RD
MONROE MI
48162-9217
US

V. Phone/Fax

Practice location:
  • Phone: 734-241-2117
  • Fax: 734-241-7589
Mailing address:
  • Phone: 734-241-2117
  • Fax: 734-241-7589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35.138408
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301107643
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: