Healthcare Provider Details

I. General information

NPI: 1710213780
Provider Name (Legal Business Name): AZA KHAGHANY MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2009
Last Update Date: 11/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 STEWART RD
MONROE MI
48162-4393
US

IV. Provider business mailing address

313 STEWART RD
MONROE MI
48162-4393
US

V. Phone/Fax

Practice location:
  • Phone: 734-244-5560
  • Fax: 734-244-5078
Mailing address:
  • Phone: 734-244-5560
  • Fax: 734-244-5078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301070712
License Number StateMI

VIII. Authorized Official

Name: DR. AZA KHAGHANY
Title or Position: PRESIDENT
Credential: MD
Phone: 734-242-2022