Provider Demographics
NPI:1972506293
Name:AHMED, RAZIUDDIN (DPM)
Entity Type:Individual
Prefix:
First Name:RAZIUDDIN
Middle Name:
Last Name:AHMED
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10570 BLUE STAR M HWY
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-8923
Mailing Address - Country:US
Mailing Address - Phone:269-978-3385
Mailing Address - Fax:269-978-2711
Practice Address - Street 1:10570 BLUE STAR M HWY
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-8923
Practice Address - Country:US
Practice Address - Phone:269-978-3385
Practice Address - Fax:269-978-2711
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE 4483213E00000X
MIRA002029213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00348699OtherRAILROAD MEDICARE
MI4952336Medicaid
MI5802579OtherBCBSM
CAE 4483Medicare ID - Type Unspecified
MI5802579OtherBCBSM
MI6182430001Medicare NSC
MIP00348699OtherRAILROAD MEDICARE