Basic Information
| Provider Information | |||||||||
| NPI: | 1003069014 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DERMATOLOGY SPECIALISTS OF CANTON, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43151 DALCOMA DRIVE | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862868720 | ||||||||
| FaxNumber: | 8667906803 | ||||||||
| Practice Location | |||||||||
| Address1: | 285 N LILLEY RD | ||||||||
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| City: | CANTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481873907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344951506 | ||||||||
| FaxNumber: | 7344951780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2008 | ||||||||
| LastUpdateDate: | 03/15/2011 | ||||||||
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| AuthorizedOfficialLastName: | HAMZAVI | ||||||||
| AuthorizedOfficialFirstName: | ILTEFAT | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7344951506 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 4301067985 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | DO8072 | 01 | MI | RAILROAD MEDICARE | OTHER |