Provider Demographics
NPI:1740868272
Name:DAVID, WADIE SHUKRI (DO)
Entity type:Individual
Prefix:MR
First Name:WADIE
Middle Name:SHUKRI
Last Name:DAVID
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22250 PROVIDENCE DR STE 705
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-6215
Mailing Address - Country:US
Mailing Address - Phone:248-552-9858
Mailing Address - Fax:248-849-9510
Practice Address - Street 1:22250 PROVIDENCE DR STE 705
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-6215
Practice Address - Country:US
Practice Address - Phone:248-552-9858
Practice Address - Fax:248-849-9510
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-29
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
MI5101027898207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty