Provider Demographics
NPI:1528261781
Name:ENTEZAMI, OMID (PT)
Entity type:Individual
Prefix:MR
First Name:OMID
Middle Name:
Last Name:ENTEZAMI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3521 BURNHAM RD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-9696
Mailing Address - Country:US
Mailing Address - Phone:734-730-5592
Mailing Address - Fax:248-356-2121
Practice Address - Street 1:21751 W 11 MILE RD
Practice Address - Street 2:SUITE 109
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-3712
Practice Address - Country:US
Practice Address - Phone:248-356-2100
Practice Address - Fax:248-356-2121
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501007593225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist