Provider Demographics
NPI:1760674295
Name:PANOSSIAN, ABRAHAM MOSES (MD)
Entity Type:Individual
Prefix:DR
First Name:ABRAHAM
Middle Name:MOSES
Last Name:PANOSSIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:APRAHAM
Other - Middle Name:MOVSES
Other - Last Name:PANOSSIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:600 S DOBSON RD BLDG A
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-5678
Mailing Address - Country:US
Mailing Address - Phone:480-786-6655
Mailing Address - Fax:
Practice Address - Street 1:600 S DOBSON RD BLDG A
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5678
Practice Address - Country:US
Practice Address - Phone:480-786-6655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-17
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA99283207R00000X
FLME101157207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000217600Medicaid
AZ658249Medicaid
AZ44704OtherLICENSE
AZZ71451Medicare PIN
FLAL846YMedicare PIN
AZ44704OtherLICENSE