Provider Demographics
NPI:1558477489
Name:BLEIBEL, WISSAM (MD)
Entity Type:Individual
Prefix:
First Name:WISSAM
Middle Name:
Last Name:BLEIBEL
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 1:2200 JEFFERSON AVE
Mailing Address - Street 2:5TH FL
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-7101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2702 NAVARRE AVE
Practice Address - Street 2:SUITE 320
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-3223
Practice Address - Country:US
Practice Address - Phone:419-696-5555
Practice Address - Fax:419-696-8499
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101245745207RG0100X
KY44628207RG0100X
OH35128599207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0172563Medicaid
KY7100227260Medicaid
KY065021Medicare PIN
KYK065020Medicare PIN