Provider Demographics
NPI:1629262787
Name:GHASSAN N. FANOUS, M.D. PA
Entity Type:Organization
Organization Name:GHASSAN N. FANOUS, M.D. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:432-582-2280
Mailing Address - Street 1:540 W 5TH ST
Mailing Address - Street 2:SUITE 420
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-5034
Mailing Address - Country:US
Mailing Address - Phone:432-582-2280
Mailing Address - Fax:432-331-9981
Practice Address - Street 1:540 W 5TH ST
Practice Address - Street 2:SUITE 420
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5034
Practice Address - Country:US
Practice Address - Phone:432-582-2280
Practice Address - Fax:432-331-9981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-31
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3306261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00603UMedicare PIN