Provider Demographics
NPI:1871622258
Name:HAIDER, MOHAMMAD ALI (DO)
Entity type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:ALI
Last Name:HAIDER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2932 BRECKENRIDGE LN
Mailing Address - Street 2:SUITE 5
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-1400
Mailing Address - Country:US
Mailing Address - Phone:502-883-1015
Mailing Address - Fax:502-883-1019
Practice Address - Street 1:2932 BRECKENRIDGE LN
Practice Address - Street 2:SUITE 5
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-1400
Practice Address - Country:US
Practice Address - Phone:502-883-1015
Practice Address - Fax:502-883-1019
Is Sole Proprietor?:No
Enumeration Date:2007-03-03
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KYTP117207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK081241Medicare PIN