Healthcare Provider Details

I. General information

NPI: 1609425180
Provider Name (Legal Business Name): WAFA A ELHASSAN MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2019
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4020 VENOY RD STE 300
WAYNE MI
48184-1899
US

IV. Provider business mailing address

39466 DORCHESTER CIR
CANTON MI
48188-5000
US

V. Phone/Fax

Practice location:
  • Phone: 734-589-1090
  • Fax: 734-589-1091
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DIANA EL MASRI
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 248-215-0048