Provider Demographics
NPI:1225020043
Name:SHAFIEMIR, MANIJEH (OD)
Entity Type:Individual
Prefix:
First Name:MANIJEH
Middle Name:
Last Name:SHAFIEMIR
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24169 WESTMONT CT
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-3656
Mailing Address - Country:US
Mailing Address - Phone:248-380-8178
Mailing Address - Fax:
Practice Address - Street 1:13530 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3574
Practice Address - Country:US
Practice Address - Phone:313-827-0779
Practice Address - Fax:313-827-0784
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003851152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN02790Medicare ID - Type Unspecified