Provider Demographics
NPI:1790703536
Name:MANSHADY, BADIOLLAH MOVAFFAGHY (MD)
Entity Type:Individual
Prefix:DR
First Name:BADIOLLAH
Middle Name:MOVAFFAGHY
Last Name:MANSHADY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18633 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48236
Mailing Address - Country:US
Mailing Address - Phone:313-886-5755
Mailing Address - Fax:313-886-3609
Practice Address - Street 1:18633 MACK AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236
Practice Address - Country:US
Practice Address - Phone:313-886-5755
Practice Address - Fax:313-886-3609
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBM033580207RR0500X, 207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Not Answered207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1393074Medicaid
MI1108204451OtherBLUE SHIELD
MI1393074Medicaid
E21187Medicare UPIN