Healthcare Provider Details

I. General information

NPI: 1952455610
Provider Name (Legal Business Name): HARRY A KEZELIAN JR D P M P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 10/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 JOHN R ST SUITE 1012
DETROIT MI
48201-2020
US

IV. Provider business mailing address

29877 TELEGRAPH RD SUITE 200
SOUTHFIELD MI
48034-1332
US

V. Phone/Fax

Practice location:
  • Phone: 313-831-6442
  • Fax:
Mailing address:
  • Phone: 248-354-0057
  • Fax: 248-723-8807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5901001098
License Number StateMI

VIII. Authorized Official

Name: HARRY ALGER KEZELIAN JR.
Title or Position: PRESIDENT
Credential: D.P.M.
Phone: 248-354-0057