Healthcare Provider Details

I. General information

NPI: 1326742909
Provider Name (Legal Business Name): MOHAMMED I DAIRYWALA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2023
Last Update Date: 06/10/2023
Certification Date: 06/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22250 PROVIDENCE DR STE 555
SOUTHFIELD MI
48075-6213
US

IV. Provider business mailing address

22250 PROVIDENCE DR STE 555
SOUTHFIELD MI
48075-6213
US

V. Phone/Fax

Practice location:
  • Phone: 248-424-5748
  • Fax: 248-443-1706
Mailing address:
  • Phone: 248-424-5748
  • Fax: 248-443-1706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number4351050855
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: