Provider Demographics
NPI:1902061054
Name:SHIDYAK, AMJAD (MD;)
Entity Type:Individual
Prefix:
First Name:AMJAD
Middle Name:
Last Name:SHIDYAK
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 1:28411 NORTHWESTERN HWY
Mailing Address - Street 2:SUITE 1050
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-5544
Mailing Address - Country:US
Mailing Address - Phone:248-354-4709
Mailing Address - Fax:248-354-4807
Practice Address - Street 1:28411 NORTHWESTERN HWY
Practice Address - Street 2:SUITE 1050
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-5544
Practice Address - Country:US
Practice Address - Phone:248-354-4709
Practice Address - Fax:248-354-4807
Is Sole Proprietor?:No
Enumeration Date:2008-07-28
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301097774207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301097774OtherMI LICENSE
MI5315048432OtherMI PHARMACY #