Healthcare Provider Details

I. General information

NPI: 1245492974
Provider Name (Legal Business Name): MARTIN SASAN PAKIDEH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 02/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 COLE RD
MONROE MI
48162-4103
US

IV. Provider business mailing address

55 COLE ROAD
MONROE MI
48162
US

V. Phone/Fax

Practice location:
  • Phone: 734-242-2022
  • Fax: 734-242-2251
Mailing address:
  • Phone: 734-242-2022
  • Fax: 734-242-2251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number5101015892
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: