Provider Demographics
NPI:1083843965
Name:GHOULAME, HOUSSEIN O
Entity Type:Individual
Prefix:MR
First Name:HOUSSEIN
Middle Name:O
Last Name:GHOULAME
Suffix:
Gender:M
Credentials:
Other - Prefix:MRS
Other - First Name:LAURA
Other - Middle Name:B
Other - Last Name:GHOULAME
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:19453 AMBER WAY
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-8389
Mailing Address - Country:US
Mailing Address - Phone:317-809-1055
Mailing Address - Fax:
Practice Address - Street 1:19453 AMBER WAY
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-8389
Practice Address - Country:US
Practice Address - Phone:317-809-1055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-13
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0430-82-9020172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver