Provider Demographics
NPI:1720224884
Name:SHAIK MOHAMMED, ABU FAZAL (MD)
Entity Type:Individual
Prefix:
First Name:ABU FAZAL
Middle Name:
Last Name:SHAIK MOHAMMED
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 674147
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-4147
Mailing Address - Country:US
Mailing Address - Phone:248-358-4892
Mailing Address - Fax:248-358-5125
Practice Address - Street 1:28411 NORTHWESTERN HWY
Practice Address - Street 2:SUITE 1050
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-5544
Practice Address - Country:US
Practice Address - Phone:248-354-4709
Practice Address - Fax:248-354-4807
Is Sole Proprietor?:No
Enumeration Date:2008-12-19
Last Update Date:2014-06-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301088545207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1346398971OtherGRP NPI
MI4301088545OtherLICENSE
MI0P41360Medicare PIN