Healthcare Provider Details

I. General information

NPI: 1306750872
Provider Name (Legal Business Name): RYAN HADDAD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 W WHITTAKER ST STE D
SALEM IL
62881-2034
US

IV. Provider business mailing address

PO BOX 27
MONROVIA CA
91017-0027
US

V. Phone/Fax

Practice location:
  • Phone: 618-740-0300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number297.011194
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: