Provider Demographics
NPI:1760524094
Name:KASSAB, WAFIK M (MD)
Entity Type:Individual
Prefix:
First Name:WAFIK
Middle Name:M
Last Name:KASSAB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:WAFIK
Other - Middle Name:M
Other - Last Name:KASSAB
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2241 PEGGY LN
Mailing Address - Street 2:SUITE B
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75042-5732
Mailing Address - Country:US
Mailing Address - Phone:972-276-3878
Mailing Address - Fax:
Practice Address - Street 1:2241 PEGGY LN
Practice Address - Street 2:SUITE B
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75042-5732
Practice Address - Country:US
Practice Address - Phone:972-276-3878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE1213208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP000BQ475Medicaid