Basic Information
| Provider Information | |||||||||
| NPI: | 1538117866 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAMZAVI | ||||||||
| FirstName: | ILTEFAT | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43151 DALCOMA DR | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480386306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862868720 | ||||||||
| FaxNumber: | 5862868723 | ||||||||
| Practice Location | |||||||||
| Address1: | 285 N LILLEY RD | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481873907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344951506 | ||||||||
| FaxNumber: | 7344951780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 12/09/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207NS0135X | IH067985 | MI | Y | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 4366016 | 05 | MI | MEDICAID | 4366320 | 05 | MI | MEDICAID | CB4874 | 01 | MI | RAILROAD MEDICARE | OTHER |