Provider Demographics
NPI:1053390427
Name:JABER, WISSAM A (MD)
Entity type:Individual
Prefix:
First Name:WISSAM
Middle Name:A
Last Name:JABER
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 1:550 PEACHTREE ST NE
Mailing Address - Street 2:MOT 6TH FLOOR CARDIOLOGY
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-2208
Mailing Address - Country:US
Mailing Address - Phone:404-686-1474
Mailing Address - Fax:404-686-4445
Practice Address - Street 1:550 PEACHTREE ST NE
Practice Address - Street 2:MOT 6TH FLOOR CARDIOLOGY
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2208
Practice Address - Country:US
Practice Address - Phone:404-686-1474
Practice Address - Fax:404-686-4445
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA66954207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA421417307P4OtherUHC/RIVER VALLEY/JD PREMIER
IA1053390427Medicaid
I04764Medicare UPIN
IA1053390427Medicare PIN