Provider Demographics
NPI:1093918302
Name:KISSO, BASSEL (MD)
Entity Type:Individual
Prefix:
First Name:BASSEL
Middle Name:
Last Name:KISSO
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 1:1505 N SWAN RD STE 121
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-4044
Mailing Address - Country:US
Mailing Address - Phone:520-795-3090
Mailing Address - Fax:520-795-3537
Practice Address - Street 1:1505 N SWAN RD STE 121
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-4044
Practice Address - Country:US
Practice Address - Phone:520-795-3090
Practice Address - Fax:520-795-3537
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ37200207RG0100X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ116332OtherMEDICARE
AZ227902Medicaid