Provider Demographics
NPI:1649834383
Name:BOU DARGHAM, BASSEL (MD)
Entity type:Individual
Prefix:
First Name:BASSEL
Middle Name:
Last Name:BOU DARGHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 636256
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6256
Mailing Address - Country:US
Mailing Address - Phone:513-585-6200
Mailing Address - Fax:513-245-3672
Practice Address - Street 1:3130 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2399
Practice Address - Country:US
Practice Address - Phone:513-584-4503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA390200000X
OH35.150362207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program