Provider Demographics
NPI:1578806253
Name:KALLOU, BRUCE (DPM)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:KALLOU
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 1:37595 W. SEVEN MILD RD
Mailing Address - Street 2:STE 370
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152
Mailing Address - Country:US
Mailing Address - Phone:248-258-0001
Mailing Address - Fax:248-258-6779
Practice Address - Street 1:37595 7 MILE RD STE 370
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152
Practice Address - Country:US
Practice Address - Phone:248-258-0001
Practice Address - Fax:248-258-6779
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-01
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002617213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty