Healthcare Provider Details

I. General information

NPI: 1275152159
Provider Name (Legal Business Name): MOHAMMED MUSHTAQ AHMED HAKIM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2020
Last Update Date: 07/14/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N EAST AVE
JACKSON MI
49201-1753
US

IV. Provider business mailing address

451 E TOWN ST APT 209
COLUMBUS OH
43215-4724
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-7836
  • Fax:
Mailing address:
  • Phone: 614-680-2552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4301514464
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number4301514464
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: