Provider Demographics
NPI:1811967268
Name:MIRKAZEMI, MEHRAN (DO)
Entity type:Individual
Prefix:DR
First Name:MEHRAN
Middle Name:
Last Name:MIRKAZEMI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22190 GARRISON ST
Mailing Address - Street 2:S301
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2260
Mailing Address - Country:US
Mailing Address - Phone:313-561-2622
Mailing Address - Fax:313-561-2774
Practice Address - Street 1:22190 GARRISON ST
Practice Address - Street 2:S301
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2260
Practice Address - Country:US
Practice Address - Phone:313-561-2622
Practice Address - Fax:313-561-2774
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013208174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialist
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4406640Medicaid
MIH02608Medicare UPIN
MI4406640Medicaid