Provider Demographics
NPI:1932866480
Name:ISSA, BASEM
Entity Type:Individual
Prefix:MR
First Name:BASEM
Middle Name:
Last Name:ISSA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6444 N BEECHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-4026
Mailing Address - Country:US
Mailing Address - Phone:909-520-4542
Mailing Address - Fax:
Practice Address - Street 1:6444 N BEECHWOOD AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92407-4026
Practice Address - Country:US
Practice Address - Phone:909-520-4542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC6607310172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver