Healthcare Provider Details

I. General information

NPI: 1245849892
Provider Name (Legal Business Name): MOHAMMAD HAIDOUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2020
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 E DOUGLAS RD STE 309
MISHAWAKA IN
46545-1467
US

IV. Provider business mailing address

11100 EUCLID AVE
CLEVELAND OH
44106-1716
US

V. Phone/Fax

Practice location:
  • Phone: 574-335-6770
  • Fax: 574-335-0779
Mailing address:
  • Phone: 216-844-3833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number57.249573
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number01096548A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA185951
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: