Healthcare Provider Details

I. General information

NPI: 1649193285
Provider Name (Legal Business Name): VANDUTCH MEDSURG PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2026
Last Update Date: 07/31/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 W 5TH ST STE 200
ROYAL OAK MI
48067-2573
US

IV. Provider business mailing address

424 W 5TH ST STE 200
ROYAL OAK MI
48067-2573
US

V. Phone/Fax

Practice location:
  • Phone: 313-460-4443
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: ALI KHAZAAL
Title or Position: OWNER
Credential: DPM
Phone: 313-460-4443