Provider Demographics
NPI:1821972548
Name:DERMATOLOGY SPECIALISTS OF GRAND RAPIDS, PLLC
Entity type:Organization
Organization Name:DERMATOLOGY SPECIALISTS OF GRAND RAPIDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:ILTEFAT
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMZAVI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-650-0995
Mailing Address - Street 1:43151 DALCOMA DR STE 4
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-6306
Mailing Address - Country:US
Mailing Address - Phone:586-876-2345
Mailing Address - Fax:
Practice Address - Street 1:1000 EAST PARIS AVE SE STE 104
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3680
Practice Address - Country:US
Practice Address - Phone:586-876-2345
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-05
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty