Provider Demographics
NPI:1881073625
Name:ALDAYOUB, WISSAM (MD)
Entity type:Individual
Prefix:DR
First Name:WISSAM
Middle Name:
Last Name:ALDAYOUB
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 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6019 WALNUT GROVE RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2113
Practice Address - Country:US
Practice Address - Phone:901-226-3610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-26
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY326407207R00000X
TN57704207R00000X
ARE-13223207R00000X
MS27701207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine