Provider Demographics
NPI:1780752543
Name:KAKISH, TARIQ (MD)
Entity type:Individual
Prefix:DR
First Name:TARIQ
Middle Name:
Last Name:KAKISH
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 1:32121 WOODWARD AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6237
Mailing Address - Country:US
Mailing Address - Phone:248-399-5492
Mailing Address - Fax:248-399-5792
Practice Address - Street 1:32121 WOODWARD AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6237
Practice Address - Country:US
Practice Address - Phone:248-399-5492
Practice Address - Fax:248-399-5792
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301067872207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00600535OtherRAILROAD MEDICARE
MI1106334211OtherBCBS BCN
MI4421922Medicaid
MIP00430910OtherMEDICARE RAILROAD
MIP00430910OtherMEDICARE RAILROAD
MI4421922Medicaid
MI0P39310001Medicare PIN