Provider Demographics
NPI:1568476166
Name:BISHARA, MOE H (MD)
Entity Type:Individual
Prefix:DR
First Name:MOE
Middle Name:H
Last Name:BISHARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 LAKE WELLBROOK DR.
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606
Mailing Address - Country:US
Mailing Address - Phone:706-389-7800
Mailing Address - Fax:706-389-7830
Practice Address - Street 1:1351 LAKE WELBROOK DR
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-7631
Practice Address - Country:US
Practice Address - Phone:706-389-7800
Practice Address - Fax:706-389-7830
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056808207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
H23840Medicare UPIN
GA06BDHZSMedicare ID - Type Unspecified