Provider Demographics
NPI:1982681409
Name:MAZHARI, ASSADOLLAH A (MD)
Entity Type:Individual
Prefix:DR
First Name:ASSADOLLAH
Middle Name:A
Last Name:MAZHARI
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 1:1560 E MAPLE RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1138
Mailing Address - Country:US
Mailing Address - Phone:877-486-7978
Mailing Address - Fax:313-745-2777
Practice Address - Street 1:43650 GARFIELD RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1120
Practice Address - Country:US
Practice Address - Phone:877-486-7978
Practice Address - Fax:313-745-2777
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301052399207T00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1891095Medicaid
MI1891095Medicaid
MI0P30630696Medicare PIN
MI0500776Medicare ID - Type Unspecified