Healthcare Provider Details

I. General information

NPI: 1649914664
Provider Name (Legal Business Name): ALI KHAZAAL DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2022
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
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: 313-460-4443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number5901400590
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: