Provider Demographics
NPI:1619968922
Name:AL-HARASTANI, MOHAMMAD (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:
Last Name:AL-HARASTANI
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 1:1083 SUNCREST DR
Mailing Address - Street 2:SUITE-A
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-4421
Mailing Address - Country:US
Mailing Address - Phone:810-245-9700
Mailing Address - Fax:810-245-9703
Practice Address - Street 1:1083 SUNCREST DR
Practice Address - Street 2:SUITE-A
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-4421
Practice Address - Country:US
Practice Address - Phone:810-245-9700
Practice Address - Fax:810-245-9703
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-04
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301067273208000000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1026494OtherHEALTH ADVANTAGE NETWORK
MI1619968922Medicaid
MI350D410030OtherBLUE CARE NETWORK
MIC3769OtherMCARE
MI41A87114OtherHEALTH PLUS
MIF76263OtherHEALTH ALLIANCE PLAN
P48210001OtherMEDICARE PTAN
MI5243111OtherAETNA
MI526OtherPPOM
MI370011198OtherMETRAHEALTH
MI8572330001OtherCIGNA
MI1026494OtherMCLAREN HEALTH PLAN
MI305-044-1237-1OtherBLUE CARE NETWORK
MI35-0-44-1237-1OtherBCBS