Healthcare Provider Details

I. General information

NPI: 1720690555
Provider Name (Legal Business Name): MOHANNAD HUSSAM AL-KHATEEB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2020
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 HARRIET ST
EVANSVILLE IN
47710-1715
US

IV. Provider business mailing address

PO BOX 632281
CINCINNATI OH
45263-2281
US

V. Phone/Fax

Practice location:
  • Phone: 812-450-7720
  • Fax: 812-450-7730
Mailing address:
  • Phone: 812-450-6815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA12603400
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number01099388A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number61915
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number25MA12603400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: