Provider Demographics
NPI:1467403675
Name:AWAN, TARIQ M (DO)
Entity Type:Individual
Prefix:
First Name:TARIQ
Middle Name:M
Last Name:AWAN
Suffix:
Gender:M
Credentials:DO
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 2253
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85002-2253
Mailing Address - Country:US
Mailing Address - Phone:602-606-8949
Mailing Address - Fax:
Practice Address - Street 1:30055 NORTHWESTERN HWY STE L-30
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3211
Practice Address - Country:US
Practice Address - Phone:248-865-4238
Practice Address - Fax:248-865-4237
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2022-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101015599207Q00000X, 207QS0010X
AZ009931207Q00000X, 207QS0010X
FLOS17051207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ009931OtherARIZONA LICENSE
MI5101015599OtherMICHIGAN LICENSE
AZ161081Medicaid