Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207V00000X | Obstetrician & Gynecologist | J3306 | TX |
NPI | 1013021146 |
---|---|
Provider Name | Ghassan N Fanous |
First Address | Odessa, TX 79761-5034 |
Second Address | Odessa, TX 79761-5034 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/08/2006 |
Last Update Date | 14/12/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
155882701 | (05) | TX |
F67998 | (02) | TX |