Provider Demographics
NPI:1598774564
Name:WAHIDUZZAMAN, MD (MD)
Entity Type:Individual
Prefix:
First Name:MD
Middle Name:
Last Name:WAHIDUZZAMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MD
Other - Middle Name:
Other - Last Name:WAHID
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11900 EAST TWELVE MILE ROAD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093
Mailing Address - Country:US
Mailing Address - Phone:586-573-5143
Mailing Address - Fax:586-573-5525
Practice Address - Street 1:11900 EAST TWELVE MILE ROAD
Practice Address - Street 2:SUITE 105
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093
Practice Address - Country:US
Practice Address - Phone:586-573-5143
Practice Address - Fax:586-573-5525
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301072692207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4499470Medicaid
H22913Medicare UPIN
MI4499470Medicaid