Provider Demographics
NPI:1487221917
Name:RUSSELL, KAZI SHAHRIAR (DO)
Entity Type:Individual
Prefix:
First Name:KAZI
Middle Name:SHAHRIAR
Last Name:RUSSELL
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 1:1661 MINOKA TRL
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-2252
Mailing Address - Country:US
Mailing Address - Phone:678-799-2090
Mailing Address - Fax:
Practice Address - Street 1:1322 E MICHIGAN AVE STE 202B
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-2109
Practice Address - Country:US
Practice Address - Phone:678-799-2090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5151015222APP21207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine