Provider Demographics
NPI:1790798304
Name:DAGHMAN, BASSAM J (MD)
Entity Type:Individual
Prefix:
First Name:BASSAM
Middle Name:J
Last Name:DAGHMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:916 WASHINGTON AVENUE
Mailing Address - Street 2:SUITE 323
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708
Mailing Address - Country:US
Mailing Address - Phone:989-891-9050
Mailing Address - Fax:898-891-9070
Practice Address - Street 1:1900 COLUMBUS AVENUE
Practice Address - Street 2:3175 COLUMBUS AVENUE
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706
Practice Address - Country:US
Practice Address - Phone:989-891-9050
Practice Address - Fax:989-891-9070
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI43010712812085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4736860Medicaid
MI4736860Medicaid
MIP19320001Medicare ID - Type Unspecified