Healthcare Provider Details

I. General information

NPI: 1235357708
Provider Name (Legal Business Name): AYESHA FATIMA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 W 13 MILE RD
ROYAL OAK MI
48073-6770
US

IV. Provider business mailing address

3535 W 13 MILE RD
ROYAL OAK MI
48073-6770
US

V. Phone/Fax

Practice location:
  • Phone: 248-551-0311
  • Fax:
Mailing address:
  • Phone: 248-551-0311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD12288
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberMD12288
License Number StateRI
# 3
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number4301079789
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: