Provider Demographics
NPI:1790949741
Name:KHAMBATTA, SHEREZADE (DO)
Entity Type:Individual
Prefix:
First Name:SHEREZADE
Middle Name:
Last Name:KHAMBATTA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50505 SCHOENHERR RD
Mailing Address - Street 2:STE 320
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-3141
Mailing Address - Country:US
Mailing Address - Phone:586-580-3062
Mailing Address - Fax:586-580-3143
Practice Address - Street 1:50505 SCHOENHERR RD
Practice Address - Street 2:STE 320
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-3141
Practice Address - Country:US
Practice Address - Phone:586-580-3062
Practice Address - Fax:586-580-3143
Is Sole Proprietor?:No
Enumeration Date:2008-07-17
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101019075207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
IAENROLLEDMedicaid
MI1790949741Medicaid
MNP00839001OtherRAILROAD MEDICARE
MNP00839001OtherRAILROAD MEDICARE
MIMI2276041Medicare PIN
MIMI2433027Medicare PIN