Provider Demographics
NPI:1144462482
Name:SULTANA R GHUZNAVI MD PC
Entity type:Organization
Organization Name:SULTANA R GHUZNAVI MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SULTANA
Authorized Official - Middle Name:R
Authorized Official - Last Name:GHUZNAVI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-292-4110
Mailing Address - Street 1:25412 GODDARD RD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-6200
Mailing Address - Country:US
Mailing Address - Phone:313-292-4110
Mailing Address - Fax:313-292-9512
Practice Address - Street 1:25412 GODDARD RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-6200
Practice Address - Country:US
Practice Address - Phone:313-292-4110
Practice Address - Fax:313-292-9512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301040612174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1432673Medicaid