Provider Demographics
NPI:1922160860
Name:AYOUBI, MOUTASSEM B (MD)
Entity Type:Individual
Prefix:MR
First Name:MOUTASSEM
Middle Name:B
Last Name:AYOUBI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:MARK
Other - Middle Name:B
Other - Last Name:AYOUBI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:310 35TH ST SE
Mailing Address - Street 2:SUITE 21
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1352
Mailing Address - Country:US
Mailing Address - Phone:304-925-6970
Mailing Address - Fax:304-925-5161
Practice Address - Street 1:310 35TH ST SE
Practice Address - Street 2:SUITE 21
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1352
Practice Address - Country:US
Practice Address - Phone:304-925-6970
Practice Address - Fax:304-925-5161
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV09974208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0112057000Medicaid
F77939Medicare UPIN