Provider Demographics
NPI:1235664996
Name:QAQISH, JIRIES AZMI (MD)
Entity Type:Individual
Prefix:
First Name:JIRIES
Middle Name:AZMI
Last Name:QAQISH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44405 WOODWARD AVE.
Mailing Address - Street 2:ST. JOSEPH MERCY - OAKLAND
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341
Mailing Address - Country:US
Mailing Address - Phone:248-858-6233
Mailing Address - Fax:
Practice Address - Street 1:44405 WOODWARD AVE.
Practice Address - Street 2:ST. JOSEPH MERCY - OAKLAND
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341
Practice Address - Country:US
Practice Address - Phone:248-858-6233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-01
Last Update Date:2021-04-01
Deactivation Date:2017-12-06
Deactivation Code:
Reactivation Date:2017-12-28
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301501438207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program