Provider Demographics
NPI:1497949812
Name:AHMED, GHAZALA AZAM (MD)
Entity Type:Individual
Prefix:
First Name:GHAZALA
Middle Name:AZAM
Last Name:AHMED
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GHAZALA
Other - Middle Name:AHMED
Other - Last Name:AZAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2421 MONROE ST STE 201
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3043
Mailing Address - Country:US
Mailing Address - Phone:313-447-0511
Mailing Address - Fax:313-447-0496
Practice Address - Street 1:2421 MONROE ST STE 201
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3043
Practice Address - Country:US
Practice Address - Phone:313-447-0511
Practice Address - Fax:313-447-0496
Is Sole Proprietor?:No
Enumeration Date:2007-08-29
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301100108207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1497949812Medicaid
MIP35290028Medicare PIN