Provider Demographics
NPI:1083847321
Name:AL-DELAIGAN, BASSIMA MOWAFFAK
Entity Type:Individual
Prefix:
First Name:BASSIMA
Middle Name:MOWAFFAK
Last Name:AL-DELAIGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 CRAMER CIR
Mailing Address - Street 2:PENNOCK 502
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-2736
Mailing Address - Country:US
Mailing Address - Phone:231-591-2222
Mailing Address - Fax:
Practice Address - Street 1:1310 CRAMER CIR
Practice Address - Street 2:PENNOCK 502
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-2736
Practice Address - Country:US
Practice Address - Phone:231-591-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-03
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004547152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0784610001OtherADMINASTAR
999998001OtherVSP
900006367OtherPRIORITY HEALTH
900E47602OtherBLUE CROSS MEDICAL
999998001OtherVSP