Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 12298 | MT |
N | 208000000X | Pediatrician | 2012014535 | MO |
Y | 208000000X | Pediatrician | 4301055614 | MI |
N | 2084N0400X | Neurologist | 63034 | WI |
N | 2084N0402X | Child Neurologist | 24539 | MS |
N | 2084N0402X | Child Neurologist | 63034 | WI |
N | 2084N0600X | Clinical Neurophysiologist | 63034 | WI |
NPI | 1104141712 |
---|---|
Provider Name | Tarif Bakdash |
First Address | Southfield, MI 48033-3849 |
Second Address | Royal Oak, MI 48073-6710 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/04/2010 |
Last Update Date | 18/06/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
05127841 | (05) | MS |
1104141712 | (05) | MO |
12298 | LICENSE (01) | MT |
192753001 | (05) | AR |
200435170A | (05) | OK |
431560263 | TRICARE (01) | MO |
P01110482 | RR MCR (01) | MO |