Provider Demographics
NPI:1396790275
Name:FARRUKH, SHAHANA (MD)
Entity type:Individual
Prefix:
First Name:SHAHANA
Middle Name:
Last Name:FARRUKH
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 1:1070 E CARO RD
Mailing Address - Street 2:
Mailing Address - City:CARO
Mailing Address - State:MI
Mailing Address - Zip Code:48723-1236
Mailing Address - Country:US
Mailing Address - Phone:989-672-2500
Mailing Address - Fax:
Practice Address - Street 1:1070 E CARO RD
Practice Address - Street 2:
Practice Address - City:CARO
Practice Address - State:MI
Practice Address - Zip Code:48723
Practice Address - Country:US
Practice Address - Phone:989-672-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301069107207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4803990Medicaid
MI4803990Medicaid
MI270129775Medicare PIN
MIP25510002Medicare PIN