Provider Demographics
NPI:1144425323
Name:MASANNAT, FARES YOUSEF (MD)
Entity Type:Individual
Prefix:
First Name:FARES
Middle Name:YOUSEF
Last Name:MASANNAT
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 1:6709 S MINNESOTA AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-2593
Mailing Address - Country:US
Mailing Address - Phone:605-322-7250
Mailing Address - Fax:605-331-6401
Practice Address - Street 1:6709 S MINNESOTA AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-2592
Practice Address - Country:US
Practice Address - Phone:605-335-1952
Practice Address - Fax:605-373-9971
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPG PERMIT # 76497207R00000X
SD7518207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDRAILROAD MEDICAREOtherP00751793
SD6632250Medicaid
SDRAILROAD MEDICAREOtherP00751793