Provider Demographics
NPI:1780799965
Name:MOUANNES, WASSIM E (MD)
Entity type:Individual
Prefix:
First Name:WASSIM
Middle Name:E
Last Name:MOUANNES
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-425-5544
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:404 S 13TH AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4345
Practice Address - Country:US
Practice Address - Phone:601-425-5544
Practice Address - Fax:601-425-5525
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18406207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09300503Medicaid
LA1782289Medicaid
MS640507572YSOtherAMERICAN ADMIN GROUP
P00249340OtherRAILROAD MEDICARE
MS640507572YSOtherAMERICAN ADMIN GROUP
P00249340OtherRAILROAD MEDICARE