Provider Demographics
NPI:1083103329
Name:AL GHARIB, RAED (DPM)
Entity Type:Individual
Prefix:
First Name:RAED
Middle Name:
Last Name:AL GHARIB
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:RAED
Other - Middle Name:
Other - Last Name:AL-GHARIB
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:29433 RYAN RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-2203
Mailing Address - Country:US
Mailing Address - Phone:586-574-0500
Mailing Address - Fax:586-574-2694
Practice Address - Street 1:29433 RYAN RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-2203
Practice Address - Country:US
Practice Address - Phone:586-574-0500
Practice Address - Fax:586-574-2694
Is Sole Proprietor?:No
Enumeration Date:2018-05-02
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5901400399213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program