Provider Demographics
NPI:1073216958
Name:MOFTAKHAR, NICO
Entity Type:Individual
Prefix:
First Name:NICO
Middle Name:
Last Name:MOFTAKHAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22201 MOROSS RD STE 80
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2169
Mailing Address - Country:US
Mailing Address - Phone:313-343-3800
Mailing Address - Fax:313-343-4756
Practice Address - Street 1:22201 MOROSS RD STE 80
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2169
Practice Address - Country:US
Practice Address - Phone:313-343-3800
Practice Address - Fax:313-343-4756
Is Sole Proprietor?:No
Enumeration Date:2023-03-22
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program