Provider Demographics
NPI:1538117866
Name:HAMZAVI, ILTEFAT H (MD)
Entity Type:Individual
Prefix:DR
First Name:ILTEFAT
Middle Name:H
Last Name:HAMZAVI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:43151 DALCOMA DR
Mailing Address - Street 2:SUITE 6
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-6306
Mailing Address - Country:US
Mailing Address - Phone:586-286-8720
Mailing Address - Fax:586-286-8723
Practice Address - Street 1:285 N LILLEY RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-3907
Practice Address - Country:US
Practice Address - Phone:734-495-1506
Practice Address - Fax:734-495-1780
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIIH067985207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4366016Medicaid
MI4366320Medicaid
MICB4874OtherRAILROAD MEDICARE
MI4366320Medicaid
MI4366016Medicaid