Provider Demographics
NPI:1174273395
Name:PERVEZ, AQSA (MD)
Entity Type:Individual
Prefix:
First Name:AQSA
Middle Name:
Last Name:PERVEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36500 S GRATIOT AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-1772
Mailing Address - Country:US
Mailing Address - Phone:586-790-9003
Mailing Address - Fax:586-493-3603
Practice Address - Street 1:36500 S GRATIOT AVE STE 102
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-1772
Practice Address - Country:US
Practice Address - Phone:586-790-9003
Practice Address - Fax:586-493-3603
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-29
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4351049279207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program