Provider Demographics
NPI:1255659587
Name:RAJJOUB, MOHANNAD (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHANNAD
Middle Name:
Last Name:RAJJOUB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 N LOGAN AVE
Mailing Address - Street 2:DANVILLE POLYCLINIC, LTD.
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-4360
Mailing Address - Country:US
Mailing Address - Phone:217-477-4719
Mailing Address - Fax:217-477-4758
Practice Address - Street 1:707 N LOGAN AVE
Practice Address - Street 2:DANVILLE POLYCLINIC, LTD.
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-4360
Practice Address - Country:US
Practice Address - Phone:217-477-4719
Practice Address - Fax:217-477-4758
Is Sole Proprietor?:No
Enumeration Date:2010-05-11
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301092218207V00000X
IL036-118894207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036118894Medicaid
IL036118894Medicaid