Healthcare Provider Details

I. General information

NPI: 1508116914
Provider Name (Legal Business Name): KHALID MUTLAG ALMUTAIRI M.D, MS.C, FRCSC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2012
Last Update Date: 06/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4660 S HAGADORN RD STE 600
EAST LANSING MI
48823-5376
US

IV. Provider business mailing address

804 SERVICE RD A201
EAST LANSING MI
48824-7015
US

V. Phone/Fax

Practice location:
  • Phone: 517-267-2460
  • Fax: 517-884-8602
Mailing address:
  • Phone: 517-884-2976
  • Fax: 517-432-3928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberMD445621
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License NumberMD445621
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License NumberMD445621
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number14794
License Number StateNV
# 5
Primary TaxonomyN
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number4301106555
License Number StateMI
# 6
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number4301106555
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: