Provider Demographics
NPI:1902016256
Name:SOUD, MOHAMMAD G (MD)
Entity type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:G
Last Name:SOUD
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 1:6012 N TEAL WOOD CIR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2231
Mailing Address - Country:US
Mailing Address - Phone:309-691-9312
Mailing Address - Fax:
Practice Address - Street 1:6012 N TEAL WOOD CIR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-2231
Practice Address - Country:US
Practice Address - Phone:309-691-9312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36091049208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics