Provider Demographics
NPI:1740492214
Name:ABU GHALYOUN, BADER (MD)
Entity type:Individual
Prefix:
First Name:BADER
Middle Name:
Last Name:ABU GHALYOUN
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 1:1801 E MARCH LN STE D400
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-6675
Mailing Address - Country:US
Mailing Address - Phone:209-464-3615
Mailing Address - Fax:209-464-1537
Practice Address - Street 1:1801 E MARCH LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-6629
Practice Address - Country:US
Practice Address - Phone:209-464-3615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24179208M00000X, 207R00000X
CAC169074207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AB4300571Medicare PIN
WVP00963559Medicare PIN