Provider Demographics
NPI:1003069014
Name:DERMATOLOGY SPECIALISTS OF CANTON, PLLC
Entity type:Organization
Organization Name:DERMATOLOGY SPECIALISTS OF CANTON, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ILTEFAT
Authorized Official - Middle Name:H
Authorized Official - Last Name:HAMZAVI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-495-1506
Mailing Address - Street 1:43151 DALCOMA DRIVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038
Mailing Address - Country:US
Mailing Address - Phone:586-286-8720
Mailing Address - Fax:866-790-6803
Practice Address - Street 1:285 N LILLEY RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-3907
Practice Address - Country:US
Practice Address - Phone:734-495-1506
Practice Address - Fax:734-495-1780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-04
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301067985207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIDO8072OtherRAILROAD MEDICARE
MIDO8072OtherRAILROAD MEDICARE