Healthcare Provider Details

I. General information

NPI: 1336076066
Provider Name (Legal Business Name): ZACHARY MOUAIKEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GENESYS PKWY
GRAND BLANC MI
48439-8065
US

IV. Provider business mailing address

17034 BROOKLANE BLVD
NORTHVILLE MI
48168-8423
US

V. Phone/Fax

Practice location:
  • Phone: 810-606-5000
  • Fax:
Mailing address:
  • Phone: 248-790-4940
  • Fax: 248-790-4940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4351056670
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: