Provider Demographics
NPI:1205883220
Name:GHANNOUM, HAYSAM (MD)
Entity type:Individual
Prefix:DR
First Name:HAYSAM
Middle Name:
Last Name:GHANNOUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 S UTICA AVE
Mailing Address - Street 2:# 414
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4909
Mailing Address - Country:US
Mailing Address - Phone:918-579-5724
Mailing Address - Fax:918-560-5791
Practice Address - Street 1:1145 S UTICA AVE
Practice Address - Street 2:STE 1105
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4000
Practice Address - Country:US
Practice Address - Phone:918-579-5724
Practice Address - Fax:918-560-5791
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK21933207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP00096057OtherRAILROAD MEDICARE PIN