Provider Demographics
NPI:1629021324
Name:SARSOUR, YAZAN MUSALLEM (DO)
Entity Type:Individual
Prefix:DR
First Name:YAZAN
Middle Name:MUSALLEM
Last Name:SARSOUR
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 1:950 W WOOSTER ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-2603
Mailing Address - Country:US
Mailing Address - Phone:419-373-7642
Mailing Address - Fax:419-704-6758
Practice Address - Street 1:950 W WOOSTER ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-2603
Practice Address - Country:US
Practice Address - Phone:419-354-8667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007644174400000X
OH34.007644207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2292004Medicaid
SA4066391Medicare PIN
OH2292004Medicaid