Provider Demographics
NPI:1538118005
Name:ABOUSSIE, MITCHELL ALBERT JR (MD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:ALBERT
Last Name:ABOUSSIE
Suffix:JR
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 1:40 DOWNS LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-1900
Mailing Address - Country:US
Mailing Address - Phone:972-770-0002
Mailing Address - Fax:972-770-0032
Practice Address - Street 1:40 DOWNS LAKE CIR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-1900
Practice Address - Country:US
Practice Address - Phone:972-770-0002
Practice Address - Fax:972-770-0032
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD23352085B0100X, 2085N0904X, 2085R0202X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00191428Medicare PIN
TXC12575Medicare UPIN