Provider Demographics
NPI:1346249653
Name:HARMOUSH, ISSAM (MD)
Entity Type:Individual
Prefix:
First Name:ISSAM
Middle Name:
Last Name:HARMOUSH
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 1:2501 JIMMY JOHNSON BLVD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77640-2000
Mailing Address - Country:US
Mailing Address - Phone:409-853-5987
Mailing Address - Fax:409-853-5978
Practice Address - Street 1:2501 JIMMY JOHNSON BLVD
Practice Address - Street 2:SUITE 403
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77640-2000
Practice Address - Country:US
Practice Address - Phone:409-853-5987
Practice Address - Fax:409-853-5978
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG4230208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX099812201Medicaid
C16607Medicare UPIN
TXQJ57Medicare ID - Type Unspecified