Provider Demographics
NPI:1417579517
Name:ALI, QANITA S (DPM)
Entity Type:Individual
Prefix:DR
First Name:QANITA
Middle Name:S
Last Name:ALI
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5250 AUTO CLUB DR STE 200
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126
Mailing Address - Country:US
Mailing Address - Phone:313-203-5300
Mailing Address - Fax:313-914-2529
Practice Address - Street 1:5250 AUTO CLUB DR STE 200
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2405
Practice Address - Country:US
Practice Address - Phone:313-203-5300
Practice Address - Fax:313-914-2529
Is Sole Proprietor?:No
Enumeration Date:2020-05-12
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901400475213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist