1134459472 NPI number — DR. MOHANNAD BASEM BISHARAT M.D.

Table of content: DR. MOHANNAD BASEM BISHARAT M.D. (NPI 1134459472)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134459472 NPI number — DR. MOHANNAD BASEM BISHARAT M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BISHARAT
Provider First Name:
MOHANNAD
Provider Middle Name:
BASEM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134459472
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3023 PERRYTON PKWY
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
PAMPA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79065-2821
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-663-5523
Provider Business Mailing Address Fax Number:
806-669-1491

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3023 PERRYTON PKWY
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
PAMPA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79065-2821
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-663-5523
Provider Business Practice Location Address Fax Number:
806-669-1491
Provider Enumeration Date:
01/08/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  25MA08532200 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X , with the licence number: Q3484 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 345256701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 023253700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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