Provider Demographics
NPI:1699798249
Name:HAKIM, SOUHA S (MD)
Entity type:Individual
Prefix:DR
First Name:SOUHA
Middle Name:S
Last Name:HAKIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-3518
Mailing Address - Country:US
Mailing Address - Phone:517-783-1779
Mailing Address - Fax:517-783-1899
Practice Address - Street 1:1418 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-3518
Practice Address - Country:US
Practice Address - Phone:517-783-1779
Practice Address - Fax:517-783-1899
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010687212080A0000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI03810061OtherBLUE CROSS BLUE SHIELD
MI03810061OtherBLUE CARE NETWORK
MI1044997-10Medicaid