Provider Demographics
NPI:1174524490
Name:JAFRY, SHEALA (MD)
Entity type:Individual
Prefix:
First Name:SHEALA
Middle Name:
Last Name:JAFRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 E. MAPLE RD
Mailing Address - Street 2:SUITE 400- CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1189
Mailing Address - Country:US
Mailing Address - Phone:248-581-5974
Mailing Address - Fax:248-581-5640
Practice Address - Street 1:1135 W UNIVERSITY DR
Practice Address - Street 2:SUITE 250
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1886
Practice Address - Country:US
Practice Address - Phone:248-650-6301
Practice Address - Fax:248-650-5486
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074850207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4637861Medicaid
MIM75620078Medicare ID - Type Unspecified
MI4637861Medicaid
MI0P30630841Medicare PIN