Provider Demographics
NPI:1992196828
Name:AL HADITHI, MOHAMMED
Entity Type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:
Last Name:AL HADITHI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 FORT CLARKE BLVD
Mailing Address - Street 2:APT # 1608
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-7140
Mailing Address - Country:US
Mailing Address - Phone:786-451-6771
Mailing Address - Fax:
Practice Address - Street 1:1110 SE 18TH PL
Practice Address - Street 2:BUILDING 200
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-5422
Practice Address - Country:US
Practice Address - Phone:352-351-3891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-13
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN21167122300000X
VA0401415133122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program