Provider Demographics
NPI:1841366267
Name:FAKHOURI, BASSAM M (MD)
Entity type:Individual
Prefix:DR
First Name:BASSAM
Middle Name:M
Last Name:FAKHOURI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BASSAM
Other - Middle Name:
Other - Last Name:FAKHOURI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8327 W PONTIAC DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-1414
Mailing Address - Country:US
Mailing Address - Phone:623-825-2769
Mailing Address - Fax:
Practice Address - Street 1:4175 S ALAMO AVE
Practice Address - Street 2:DAVIS-MONTHAN AFB
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85707-6097
Practice Address - Country:US
Practice Address - Phone:520-228-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27732208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics