Basic Information
| Provider Information | |||||||||
| NPI: | 1265530687 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAIBA | ||||||||
| FirstName: | MOUTAZ | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3490 CALKINS RD | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107337741 | ||||||||
| FaxNumber: | 8107338898 | ||||||||
| Practice Location | |||||||||
| Address1: | 3490 CALKINS RD | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107337741 | ||||||||
| FaxNumber: | 8107338898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 03/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 088821 | MI | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 4301088821 | MI | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 1265530687 | 05 | MI | MEDICAID |