=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477068310
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TARIK ATIF ALI DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2017
-----------------------------------------------------
Last Update Date | 11/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5901 W VERNOR HWY
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48209-2180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-554-4357
-----------------------------------------------------
Fax | 313-554-1565
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15408 AUBURNDALE ST
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48154-3128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-788-9466
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 5101025422
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------