Provider Demographics
NPI:1285428912
Name:ALQAZZAZ, WISAM
Entity type:Individual
Prefix:
First Name:WISAM
Middle Name:
Last Name:ALQAZZAZ
Suffix:
Gender:
Credentials:
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 310
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-0310
Mailing Address - Country:US
Mailing Address - Phone:562-213-5621
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 310
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-0310
Practice Address - Country:US
Practice Address - Phone:562-213-5621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-07
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174200000X, 177F00000X, 3336M0002X, 347C00000X
MI5802020115343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No174200000XOther Service ProvidersMeals
No177F00000XOther Service ProvidersLodging
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No347C00000XTransportation ServicesPrivate Vehicle