Provider Demographics
NPI:1629708144
Name:ALDARAISEH, BASHAR KAMALELDIN AHMAD (MBBS)
Entity Type:Individual
Prefix:
First Name:BASHAR
Middle Name:KAMALELDIN AHMAD
Last Name:ALDARAISEH
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 DELAWARE ST SE MMC 609 MAYO D142
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-624-8133
Mailing Address - Fax:
Practice Address - Street 1:420 DELAWARE ST SE MMC 609 MAYO D142
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-624-8133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-16
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program