Provider Demographics
NPI:1275552275
Name:HATAHET, MOHAMAD HAZEM (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMAD
Middle Name:HAZEM
Last Name:HATAHET
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 1:4235 SECOR RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-4231
Mailing Address - Country:US
Mailing Address - Phone:419-473-3561
Mailing Address - Fax:
Practice Address - Street 1:7007 LIGHTHOUSE WAY
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-7000
Practice Address - Country:US
Practice Address - Phone:419-874-3246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301081495207R00000X
OH35088079207RN0300X
TXP0224207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00409913OtherRR MEDICARE
OH2701259Medicaid
HA4195721Medicare PIN
OHH400850Medicare PIN