Provider Demographics
NPI:1437534682
Name:HASSOUBA, MAHMOUD (MD)
Entity Type:Individual
Prefix:
First Name:MAHMOUD
Middle Name:
Last Name:HASSOUBA
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 1:4100 TARRAGON CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-6241
Mailing Address - Country:US
Mailing Address - Phone:203-303-4950
Mailing Address - Fax:
Practice Address - Street 1:1068 CRESTHAVEN RD STE 500
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-0846
Practice Address - Country:US
Practice Address - Phone:901-866-8525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-29
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.025819390200000X
TN635402086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program