Provider Demographics
NPI:1164460481
Name:KHALIL, MOHAMMAD FAYEZ (DPM)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:FAYEZ
Last Name:KHALIL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1628 FORD AVE
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192-2304
Mailing Address - Country:US
Mailing Address - Phone:734-284-1333
Mailing Address - Fax:734-284-1311
Practice Address - Street 1:20905 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-5360
Practice Address - Country:US
Practice Address - Phone:248-423-4220
Practice Address - Fax:248-423-4221
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002133213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP14070003Medicare ID - Type Unspecified