Provider Demographics
NPI:1609829639
Name:BISHARA, HAYTHAM B (MD)
Entity Type:Individual
Prefix:
First Name:HAYTHAM
Middle Name:B
Last Name:BISHARA
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:PO BOX 1891
Mailing Address - Street 2:
Mailing Address - City:MANY
Mailing Address - State:LA
Mailing Address - Zip Code:71449-1891
Mailing Address - Country:US
Mailing Address - Phone:318-590-1301
Mailing Address - Fax:
Practice Address - Street 1:240 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:MANY
Practice Address - State:LA
Practice Address - Zip Code:71449-3718
Practice Address - Country:US
Practice Address - Phone:318-256-5691
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13078R207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1553573Medicaid
LAH05016Medicare UPIN
LA4F828CQ31Medicare ID - Type Unspecified