Healthcare Provider Details

I. General information

NPI: 1225370331
Provider Name (Legal Business Name): HAITHAM AL-WAHAB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2013
Last Update Date: 11/24/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6431 FANNIN ST
HOUSTON TX
77030-1501
US

IV. Provider business mailing address

6431 FANNIN ST SUITE MSB 3.228
HOUSTON TX
77030-1501
US

V. Phone/Fax

Practice location:
  • Phone: 713-500-6016
  • Fax:
Mailing address:
  • Phone: 713-500-5650
  • Fax: 713-500-0588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR9264
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberR9462
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: