Provider Demographics
NPI:1598774762
Name:KOUSA, HAITHAM J (MD)
Entity Type:Individual
Prefix:DR
First Name:HAITHAM
Middle Name:J
Last Name:KOUSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOSEPH
Other - Middle Name:
Other - Last Name:KOUSA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:9485 MENTOR AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-4597
Mailing Address - Country:US
Mailing Address - Phone:440-205-5770
Mailing Address - Fax:440-205-7202
Practice Address - Street 1:9485 MENTOR AVE STE 104
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-8722
Practice Address - Country:US
Practice Address - Phone:440-205-5770
Practice Address - Fax:440-205-7202
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-06
Last Update Date:2016-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH60918207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0919911Medicaid
OH0919911Medicaid
OH0730972Medicare ID - Type Unspecified