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General NPI Number Information
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NPI Number | 1821972548
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Entity Type | Organization
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Legal Business Name | DERMATOLOGY SPECIALISTS OF GRAND RAPIDS, PLLC
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Dates
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Enumeration Date | 08/05/2025
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Last Update Date | 08/05/2025
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Provider Practice Location Address
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Address Line | 1000 EAST PARIS AVE SE STE 104
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City | GRAND RAPIDS
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State | MI
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Zip | 49546-3680
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Country | US
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Telephone | 586-876-2345
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Fax |
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Provider Business Mailing Address
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Address Line | 43151 DALCOMA DR STE 4
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City | CLINTON TOWNSHIP
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State | MI
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Zip | 48038-6306
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Country | US
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Telephone | 586-876-2345
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Fax |
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Authorized Official
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Title or Position | M.D.
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Name | ILTEFAT HAMZAVI
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Credential |
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Telephone | 810-650-0995
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number |
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License Number State |
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