Provider Demographics
NPI:1538664511
Name:HANALLA, BASSEM (DO)
Entity Type:Individual
Prefix:
First Name:BASSEM
Middle Name:
Last Name:HANALLA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 E TWIGGS ST STE 103
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-3925
Mailing Address - Country:US
Mailing Address - Phone:813-228-7696
Mailing Address - Fax:
Practice Address - Street 1:625 E TWIGGS ST STE 103
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602-3925
Practice Address - Country:US
Practice Address - Phone:813-228-7696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS18723208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation