Healthcare Provider Details

I. General information

NPI: 1619968922
Provider Name (Legal Business Name): MOHAMMAD AL-HARASTANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 02/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1083 SUNCREST DR SUITE-A
LAPEER MI
48446-4421
US

IV. Provider business mailing address

1083 SUNCREST DR SUITE-A
LAPEER MI
48446-4421
US

V. Phone/Fax

Practice location:
  • Phone: 810-245-9700
  • Fax: 810-245-9703
Mailing address:
  • Phone: 810-245-9700
  • Fax: 810-245-9703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301067273
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number4301067273
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: