Provider Demographics
NPI:1497765598
Name:HOSSINO, HATEM MAHMOUD (MD)
Entity Type:Individual
Prefix:
First Name:HATEM
Middle Name:MAHMOUD
Last Name:HOSSINO
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 1:415 MORRIS ST
Mailing Address - Street 2:STE 101
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1842
Mailing Address - Country:US
Mailing Address - Phone:304-343-8181
Mailing Address - Fax:304-343-8247
Practice Address - Street 1:415 MORRIS ST
Practice Address - Street 2:STE 101
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1842
Practice Address - Country:US
Practice Address - Phone:304-343-8181
Practice Address - Fax:304-343-8247
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV10690208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0127996000Medicaid
KY64026743Medicaid
KY64026743Medicaid
WV0127996000Medicaid