Provider Demographics
NPI:1508109018
Name:BOZORGI, ALIREZA (MD,)
Entity Type:Individual
Prefix:DR
First Name:ALIREZA
Middle Name:
Last Name:BOZORGI
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17000 EXECUTIVE PLAZA DR STE 101
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2793
Mailing Address - Country:US
Mailing Address - Phone:313-565-4948
Mailing Address - Fax:313-565-4989
Practice Address - Street 1:17000 EXECUTIVE PLAZA DR STE 101
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2793
Practice Address - Country:US
Practice Address - Phone:313-565-4948
Practice Address - Fax:313-565-4989
Is Sole Proprietor?:No
Enumeration Date:2013-04-03
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.1315082084N0400X
390200000X
MI43015051552084P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program