Basic Information
| Provider Information | |||||||||
| NPI: | 1508116914 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALMUTAIRI | ||||||||
| FirstName: | KHALID | ||||||||
| MiddleName: | MUTLAG | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D, MS.C, FRCSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 804 SERVICE RD | ||||||||
| Address2: | A201 | ||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488247015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178842976 | ||||||||
| FaxNumber: | 5174323928 | ||||||||
| Practice Location | |||||||||
| Address1: | 4660 S HAGADORN RD | ||||||||
| Address2: | STE 600 | ||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488235376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172672460 | ||||||||
| FaxNumber: | 5178848602 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2012 | ||||||||
| LastUpdateDate: | 06/08/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | MD445621 | PA | N | Allopathic & Osteopathic Physicians | Plastic Surgery | 2082S0099X | MD445621 | PA | N | Allopathic & Osteopathic Physicians | Plastic Surgery | Plastic Surgery Within the Head and Neck | 2082S0105X | MD445621 | PA | N | Allopathic & Osteopathic Physicians | Plastic Surgery | Surgery of the Hand | 208200000X | 14794 | NV | N | Allopathic & Osteopathic Physicians | Plastic Surgery | 2086S0105X | 4301106555 | MI | N | Allopathic & Osteopathic Physicians | Surgery | Surgery of the Hand | 208200000X | 4301106555 | MI | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1508116914 | 05 | MI | MEDICAID |