Provider Demographics
NPI:1275505695
Name:KHANZODE, SATISH R (MD)
Entity Type:Individual
Prefix:
First Name:SATISH
Middle Name:R
Last Name:KHANZODE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27774 FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-2352
Mailing Address - Country:US
Mailing Address - Phone:248-356-5555
Mailing Address - Fax:248-356-5544
Practice Address - Street 1:20720 PLYMOUTH RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-1275
Practice Address - Country:US
Practice Address - Phone:313-493-4330
Practice Address - Fax:313-493-4419
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301062464207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4600389-10Medicaid
MIN90740004Medicare ID - Type Unspecified
MI4600389-10Medicaid