Healthcare Provider Details

I. General information

NPI: 1174055958
Provider Name (Legal Business Name): KAMAL KHORFAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2017
Last Update Date: 08/18/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 N SHIAWASSEE ST STE 202
OWOSSO MI
48867-1632
US

IV. Provider business mailing address

721 N SHIAWASSEE ST STE 202
OWOSSO MI
48867-1632
US

V. Phone/Fax

Practice location:
  • Phone: 989-729-1600
  • Fax: 989-729-4070
Mailing address:
  • Phone: 989-729-1600
  • Fax: 989-729-4070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberA169880
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number4301509454
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: