Provider Demographics
NPI:1801962691
Name:NAKKASH, ENAS (MD,PC)
Entity type:Individual
Prefix:
First Name:ENAS
Middle Name:
Last Name:NAKKASH
Suffix:
Gender:F
Credentials:MD,PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 279
Mailing Address - Street 2:22039 JOHNR RD
Mailing Address - City:HAZEL PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48030-0279
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1899 E WATTLES RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-5082
Practice Address - Country:US
Practice Address - Phone:248-526-9999
Practice Address - Fax:248-526-9089
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-26
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301077105207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4724250Medicaid
MII29651Medicare UPIN
MI4724250Medicaid