Provider Demographics
NPI:1154563369
Name:REZAZADEGAN, MALIHE (MD)
Entity type:Individual
Prefix:
First Name:MALIHE
Middle Name:
Last Name:REZAZADEGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48519 BINGHAMPTON DR
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168-9663
Mailing Address - Country:US
Mailing Address - Phone:248-982-6856
Mailing Address - Fax:
Practice Address - Street 1:24 FRANK LLOYD WRIGHT DR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-9484
Practice Address - Country:US
Practice Address - Phone:734-747-6766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-02
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301099748207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program