Provider Demographics
NPI:1629083035
Name:KEZELIAN, HARRY ALGER JR (DPM)
Entity Type:Individual
Prefix:
First Name:HARRY
Middle Name:ALGER
Last Name:KEZELIAN
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:29877 TELEGRAPH RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1332
Mailing Address - Country:US
Mailing Address - Phone:248-354-0057
Mailing Address - Fax:248-809-6071
Practice Address - Street 1:4160 JOHN R ST
Practice Address - Street 2:SUITE 1012
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2020
Practice Address - Country:US
Practice Address - Phone:313-831-6442
Practice Address - Fax:313-831-6513
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5901001098213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3113830Medicaid
MIT34329Medicare UPIN
MI3113830Medicaid
MI5051600002Medicare NSC