Healthcare Provider Details

I. General information

NPI: 1720224884
Provider Name (Legal Business Name): ABU FAZAL SHAIK MOHAMMED M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2008
Last Update Date: 06/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28411 NORTHWESTERN HWY SUITE 1050
SOUTHFIELD MI
48034-5544
US

IV. Provider business mailing address

PO BOX 674147
DETROIT MI
48267-4147
US

V. Phone/Fax

Practice location:
  • Phone: 248-354-4709
  • Fax: 248-354-4807
Mailing address:
  • Phone: 248-358-4892
  • Fax: 248-358-5125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301088545
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: