Healthcare Provider Details

I. General information

NPI: 1205280294
Provider Name (Legal Business Name): MOHAMMAD B HAIDAR D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2016
Last Update Date: 08/04/2021
Certification Date: 08/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 CHARLES ST STE 100
ROCKFORD IL
61104-2200
US

IV. Provider business mailing address

PO BOX 78866
MILWAUKEE WI
53278-8866
US

V. Phone/Fax

Practice location:
  • Phone: 779-696-8700
  • Fax:
Mailing address:
  • Phone: 779-696-7150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036156252
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: