Provider Demographics
NPI:1568880136
Name:RHAYEM, WISSAM
Entity Type:Individual
Prefix:
First Name:WISSAM
Middle Name:
Last Name:RHAYEM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15122 MORRISON ST
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1201
Mailing Address - Country:US
Mailing Address - Phone:240-623-1985
Mailing Address - Fax:818-671-1298
Practice Address - Street 1:15122 MORRISON ST
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1201
Practice Address - Country:US
Practice Address - Phone:240-623-1985
Practice Address - Fax:818-671-1298
Is Sole Proprietor?:No
Enumeration Date:2014-04-01
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA173652207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program