Provider Demographics
NPI:1104938257
Name:KHAMBATI, SHABBIR (MD)
Entity type:Individual
Prefix:
First Name:SHABBIR
Middle Name:
Last Name:KHAMBATI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35776 HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-3205
Mailing Address - Country:US
Mailing Address - Phone:586-792-3891
Mailing Address - Fax:
Practice Address - Street 1:35426 HARPER AVE
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48035-3205
Practice Address - Country:US
Practice Address - Phone:586-792-3891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070791Q207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0501160OtherBLUE CARE NETWORK - BCBS
MI140631OtherGREAT LAKES
MI4606945Medicaid
MIH42351OtherHAP
MIH42351OtherHAP
MI140631OtherGREAT LAKES