1487612727 NPI number — GHANEM DAGHESTANI MD PA

Table of content: (NPI 1487612727)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487612727 NPI number — GHANEM DAGHESTANI MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GHANEM DAGHESTANI MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1487612727
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1348
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDINBURG
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78540-1348
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-687-4600
Provider Business Mailing Address Fax Number:
956-631-4555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2717 MICHAEL ANGELO
Provider Second Line Business Practice Location Address:
SUITE 303
Provider Business Practice Location Address City Name:
EDINBURG
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78539-1408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-687-4600
Provider Business Practice Location Address Fax Number:
956-631-4555
Provider Enumeration Date:
05/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DAGHESTANI
Authorized Official First Name:
GHANEM
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER PRESIDENT
Authorized Official Telephone Number:
956-542-8400

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00317438 . This is a "RAILROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 180265401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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