Healthcare Provider Details

I. General information

NPI: 1235802182
Provider Name (Legal Business Name): MOHAMMAD MAHMOUD BALLOUT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2021
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N PERRY ST
PONTIAC MI
48342-2217
US

IV. Provider business mailing address

50 N PERRY ST
PONTIAC MI
48342-2217
US

V. Phone/Fax

Practice location:
  • Phone: 248-338-5332
  • Fax: 313-998-2171
Mailing address:
  • Phone:
  • Fax: 313-998-2171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301514355
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4301514355
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: