Provider Demographics
NPI:1720123250
Name:KHABBAZ, BASSAM (MD)
Entity Type:Individual
Prefix:
First Name:BASSAM
Middle Name:
Last Name:KHABBAZ
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 1:2295 DIAMOND HILL RD
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:RI
Mailing Address - Zip Code:02864-5104
Mailing Address - Country:US
Mailing Address - Phone:401-333-3445
Mailing Address - Fax:401-333-3465
Practice Address - Street 1:2295 DIAMOND HILL RD
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:RI
Practice Address - Zip Code:02864-5104
Practice Address - Country:US
Practice Address - Phone:401-333-3445
Practice Address - Fax:401-333-3465
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI10573207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9004563Medicaid
RI9004563Medicaid
RI119004563Medicare ID - Type Unspecified