Healthcare Provider Details

I. General information

NPI: 1871591313
Provider Name (Legal Business Name): ZAKARI TATA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21701 W 11 MILE RD STE 5
SOUTHFIELD MI
48076-3713
US

IV. Provider business mailing address

21701 W 11 MILE RD STE 5
SOUTHFIELD MI
48076-3713
US

V. Phone/Fax

Practice location:
  • Phone: 249-569-7550
  • Fax:
Mailing address:
  • Phone: 248-569-7550
  • Fax: 313-561-0277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301065399
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number4301065399
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number1040349825
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: