Provider Demographics
NPI:1982695276
Name:ANTOUN, BASIM WADIH (MD)
Entity Type:Individual
Prefix:DR
First Name:BASIM
Middle Name:WADIH
Last Name:ANTOUN
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:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-1559
Mailing Address - Country:US
Mailing Address - Phone:304-487-1076
Mailing Address - Fax:304-425-9499
Practice Address - Street 1:608 NEW HOPE RD STE 7
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2287
Practice Address - Country:US
Practice Address - Phone:304-487-1076
Practice Address - Fax:304-425-9499
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV174472085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
440193OtherANTHEM BCBS
KY64310295Medicaid
F65965Medicare UPIN
VA7234431Medicaid
WV0119724-000Medicaid