Healthcare Provider Details

I. General information

NPI: 1699798249
Provider Name (Legal Business Name): SOUHA S HAKIM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 01/18/2021
Certification Date: 01/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1418 E MICHIGAN AVE
JACKSON MI
49202-3518
US

IV. Provider business mailing address

1418 E MICHIGAN AVE
JACKSON MI
49202-3518
US

V. Phone/Fax

Practice location:
  • Phone: 517-783-1779
  • Fax: 517-783-1899
Mailing address:
  • Phone: 517-783-1779
  • Fax: 517-783-1899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number4301068721
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301068721
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: