Provider Demographics
NPI:1275503856
Name:WAHAB, BASEEM
Entity Type:Individual
Prefix:DR
First Name:BASEEM
Middle Name:
Last Name:WAHAB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2044
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48123-2044
Mailing Address - Country:US
Mailing Address - Phone:248-387-9595
Mailing Address - Fax:
Practice Address - Street 1:22137 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2204
Practice Address - Country:US
Practice Address - Phone:248-387-9595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1176152W00000X
MI4901004506152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ727688Medicaid
AZ727688Medicaid
AZ68242Medicare ID - Type Unspecified
AZU88562Medicare UPIN
AZ69942Medicare ID - Type Unspecified