Provider Demographics
NPI:1104082809
Name:FARHAT, MOHAMED (MD)
Entity type:Individual
Prefix:
First Name:MOHAMED
Middle Name:
Last Name:FARHAT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E WAYNE ST STE 510
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-2349
Mailing Address - Country:US
Mailing Address - Phone:574-334-5390
Mailing Address - Fax:574-334-5368
Practice Address - Street 1:1205 S MAIN ST
Practice Address - Street 2:SUITE 301
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-3676
Practice Address - Country:US
Practice Address - Phone:219-661-1640
Practice Address - Fax:219-661-8066
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-116126207R00000X
IN01066282A207RH0003X, 207RX0202X
MI4301095492207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200947020Medicaid
MI1104082809Medicaid
INP00760538OtherRR MEDICARE
MIN43780012Medicare PIN
MI1104082809Medicaid