Provider Demographics
NPI:1528156601
Name:HARIRI, MORTEZA (MD)
Entity type:Individual
Prefix:DR
First Name:MORTEZA
Middle Name:
Last Name:HARIRI
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 1:14555 LEVAN RD STE 409
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-5085
Mailing Address - Country:US
Mailing Address - Phone:734-462-4070
Mailing Address - Fax:734-462-6370
Practice Address - Street 1:14555 LEVAN RD
Practice Address - Street 2:STE 409
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-5083
Practice Address - Country:US
Practice Address - Phone:734-462-4070
Practice Address - Fax:734-462-6370
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010327882086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1061010Medicaid
MIA73726Medicare UPIN
MI0824083Medicare ID - Type Unspecified