Healthcare Provider Details

I. General information

NPI: 1124091376
Provider Name (Legal Business Name): ISSA T. HADDAD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9720 DIX
DEARBORN MI
48120-1566
US

IV. Provider business mailing address

9720 DIX
DEARBORN MI
48120-1566
US

V. Phone/Fax

Practice location:
  • Phone: 313-841-1680
  • Fax: 313-841-3123
Mailing address:
  • Phone: 313-841-1680
  • Fax: 313-841-3123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberBH7862089
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: