Healthcare Provider Details

I. General information

NPI: 1659546414
Provider Name (Legal Business Name): MOHANAD JOUDEH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 08/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 ELISHA AVE
ZION IL
60099-2676
US

IV. Provider business mailing address

1860 PAYSPHERE CIR
CHICAGO IL
60674-0018
US

V. Phone/Fax

Practice location:
  • Phone: 847-731-5050
  • Fax:
Mailing address:
  • Phone: 815-741-2900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036127003
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: