Basic Information
| Provider Information | |||||||||
| NPI: | 1275552275 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HATAHET | ||||||||
| FirstName: | MOHAMAD | ||||||||
| MiddleName: | HAZEM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4235 SECOR RD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436234231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194733561 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7007 LIGHTHOUSE WAY | ||||||||
| Address2: | |||||||||
| City: | PERRYSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435517000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198743246 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 05/09/2016 | ||||||||
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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 | 207R00000X | 4301081495 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | 35088079 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | P00409913 | 01 | OH | RR MEDICARE | OTHER | 2701259 | 05 | OH | MEDICAID |