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General NPI Number Information
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NPI Number | 1528261781
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Entity Type | Individual
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Provider Name | OMID ENTEZAMI PT
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Gender | Male
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Dates
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Enumeration Date | 06/06/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 21751 W 11 MILE RD SUITE 109
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City | SOUTHFIELD
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State | MI
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Zip | 48076-3712
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Country | US
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Telephone | 248-356-2100
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Fax | 248-356-2121
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Provider Business Mailing Address
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Address Line | 3521 BURNHAM RD
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City | ANN ARBOR
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State | MI
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Zip | 48108-9696
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Country | US
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Telephone | 734-730-5592
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Fax | 248-356-2121
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 5501007593
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License Number State | MI
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