Healthcare Provider Details

I. General information

NPI: 1003883265
Provider Name (Legal Business Name): MOHAMMAD I HUSSAIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 ST MARYS DR SUITE 203 E
EVANSVILLE IN
47714
US

IV. Provider business mailing address

801 ST MARYS DR SUITE 203 E
EVANSVILLE IN
47714
US

V. Phone/Fax

Practice location:
  • Phone: 812-479-8566
  • Fax:
Mailing address:
  • Phone: 812-479-8566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number01030793
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01030793A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: