=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275631764
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOHAMMAD GHAFFARLOO M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15945 19 MILE RD SUITE 100
-----------------------------------------------------
City | CLINTON TOWNSHIP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48038-1147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-286-8677
-----------------------------------------------------
Fax | 586-286-8781
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15945 19 MILE RD SUITE 100
-----------------------------------------------------
City | CLINTON TOWNSHIP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48038-1147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-286-8677
-----------------------------------------------------
Fax | 586-286-8781
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number | 4301056996
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------