Provider Demographics
NPI:1053486985
Name:FAHOUM, BASHAR (MD)
Entity type:Individual
Prefix:
First Name:BASHAR
Middle Name:
Last Name:FAHOUM
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 1:270 FLAGG PL
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-1134
Mailing Address - Country:US
Mailing Address - Phone:718-780-3290
Mailing Address - Fax:718-780-3154
Practice Address - Street 1:506 6TH ST
Practice Address - Street 2:DEPT OF SURGERY
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-3609
Practice Address - Country:US
Practice Address - Phone:718-780-3288
Practice Address - Fax:718-780-3154
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY192383208600000X, 2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01484844Medicaid
NY71H162Medicare ID - Type Unspecified
NY01484844Medicaid