Provider Demographics
NPI:1861439788
Name:WADOOD, SHAZIA (MD)
Entity Type:Individual
Prefix:
First Name:SHAZIA
Middle Name:
Last Name:WADOOD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12170 CONANT ST
Mailing Address - Street 2:STE C2
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48212-4137
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12170 CONANT ST
Practice Address - Street 2:UNIT: C/2
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48212
Practice Address - Country:US
Practice Address - Phone:586-604-8108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079852207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI491643810Medicaid