=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144537622
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOHAMMED BAZZI D.P.M
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2010
-----------------------------------------------------
Last Update Date | 03/09/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7633 E JEFFERSON AVE STE 250
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48214-3730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-821-3338
-----------------------------------------------------
Fax | 313-823-5363
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7633 E JEFFERSON AVE STE 250
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48214-3730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-821-3338
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 5901002374
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------