Provider Demographics
NPI:1124021829
Name:RAZZOUK, BASSEM I (MD)
Entity Type:Individual
Prefix:DR
First Name:BASSEM
Middle Name:I
Last Name:RAZZOUK
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 1:10330 N MERIDIAN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2001 W 86TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1902
Practice Address - Country:US
Practice Address - Phone:317-338-4673
Practice Address - Fax:317-338-3227
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063092A2080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1550469Medicaid
MO205028707Medicaid
KY64928971Medicaid
SCQ30048Medicaid
MS00119428Medicaid
VA006737242Medicaid
TN3898886Medicaid
AL009913930Medicaid
TX060502401Medicaid
WY1135341 00Medicaid
ME422400000Medicaid
IA0535740Medicaid
OK100017620AMedicaid
IN200179550AMedicaid
NC7611308Medicaid
IA0535740Medicaid
AL009913930Medicaid
KY64928971Medicaid
VA006737242Medicaid