Provider Demographics
NPI:1134459472
Name:BISHARAT, MOHANNAD BASEM (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHANNAD
Middle Name:BASEM
Last Name:BISHARAT
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:3023 PERRYTON PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PAMPA
Mailing Address - State:TX
Mailing Address - Zip Code:79065-2821
Mailing Address - Country:US
Mailing Address - Phone:806-663-5523
Mailing Address - Fax:806-669-1491
Practice Address - Street 1:3023 PERRYTON PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:PAMPA
Practice Address - State:TX
Practice Address - Zip Code:79065-2821
Practice Address - Country:US
Practice Address - Phone:806-663-5523
Practice Address - Fax:806-669-1491
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-08
Last Update Date:2016-08-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA08532200207R00000X
TXQ3484207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX345256701Medicaid
TX404894YNL4Medicare PIN