Provider Demographics
NPI:1013021146
Name:FANOUS, GHASSAN N (MD)
Entity Type:Individual
Prefix:
First Name:GHASSAN
Middle Name:N
Last Name:FANOUS
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 1:540 W 5TH ST
Mailing Address - Street 2:SUITE 420
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-5034
Mailing Address - Country:US
Mailing Address - Phone:432-582-2280
Mailing Address - Fax:432-331-9981
Practice Address - Street 1:540 W 5TH ST
Practice Address - Street 2:SUITE 420
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5034
Practice Address - Country:US
Practice Address - Phone:432-582-2280
Practice Address - Fax:432-331-9981
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3306207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX155882701Medicaid
TX8A2676Medicare PIN
TX155882701Medicaid