1871667071 NPI number — DR. WALID DEMASHKIEH M.D.

Table of content: DR. WALID DEMASHKIEH M.D. (NPI 1871667071)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871667071 NPI number — DR. WALID DEMASHKIEH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEMASHKIEH
Provider First Name:
WALID
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871667071
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 610669
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT HURON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48061-0669
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-985-1884
Provider Business Mailing Address Fax Number:
810-966-3025

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2609 ELECTRIC AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
PORT HURON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48060-6589
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-984-1148
Provider Business Practice Location Address Fax Number:
810-984-1149
Provider Enumeration Date:
11/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  4301039123 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4061902 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0740003 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2640474 TYPE 10 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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