Provider Demographics
NPI:1417065855
Name:KHAGHANY, AZADEH (MD)
Entity Type:Individual
Prefix:DR
First Name:AZADEH
Middle Name:
Last Name:KHAGHANY
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 1:313 STEWART RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-4393
Mailing Address - Country:US
Mailing Address - Phone:734-244-5560
Mailing Address - Fax:734-244-5078
Practice Address - Street 1:313 STEWART RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-4393
Practice Address - Country:US
Practice Address - Phone:734-244-5560
Practice Address - Fax:734-244-5078
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-27
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070712208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104604584Medicaid
MIAK070712OtherBC/BS OF MICHIGAN
MIAK070712OtherBC/BS OF MICHIGAN
MIM48310091Medicare ID - Type Unspecified