Provider Demographics
NPI:1932107794
Name:VAZIRI, SHOLEH (MD)
Entity Type:Individual
Prefix:
First Name:SHOLEH
Middle Name:
Last Name:VAZIRI
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 1:6770 DIXIE HWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-2087
Mailing Address - Country:US
Mailing Address - Phone:248-625-2621
Mailing Address - Fax:248-625-8938
Practice Address - Street 1:6770 DIXIE HWY
Practice Address - Street 2:SUITE 200
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-2087
Practice Address - Country:US
Practice Address - Phone:248-625-2621
Practice Address - Fax:248-625-8938
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISV071408207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1106332741OtherBCBS IND
MI1932107794Medicaid
MIP00943708OtherRAILROAD MEDICARE IND PIN
MI1932107794Medicaid
MI1106332741OtherBCBS IND