Provider Demographics
NPI:1780671776
Name:SANJAGHSAZ, HAMID (DO)
Entity Type:Individual
Prefix:DR
First Name:HAMID
Middle Name:
Last Name:SANJAGHSAZ
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 1:24346 W WARREN ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-2234
Mailing Address - Country:US
Mailing Address - Phone:313-563-1001
Mailing Address - Fax:313-563-1003
Practice Address - Street 1:24346 W WARREN ST
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-2234
Practice Address - Country:US
Practice Address - Phone:313-563-1001
Practice Address - Fax:313-563-1003
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012203207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4712278Medicaid
MI4711109Medicaid
MI4712278Medicaid