Healthcare Provider Details

I. General information

NPI: 1619359874
Provider Name (Legal Business Name): BASSEM GHOBRIAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2015
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W HOSPITAL RD
FRENCH CAMP CA
95231-9693
US

IV. Provider business mailing address

PO BOX 1020
STOCKTON CA
95201-3120
US

V. Phone/Fax

Practice location:
  • Phone: 209-468-6000
  • Fax: 209-468-7042
Mailing address:
  • Phone: 209-468-6000
  • Fax: 209-468-7042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberA153509
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: