Healthcare Provider Details

I. General information

NPI: 1922080563
Provider Name (Legal Business Name): FIZUL HUSSAIN BACCHUS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 04/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

863 BUTTNER PLACE SUITE 103
DOVER DE
19904-2334
US

IV. Provider business mailing address

863 BUTTNER PLACE SUITE 103
DOVER DE
19904-2334
US

V. Phone/Fax

Practice location:
  • Phone: 302-734-3331
  • Fax: 302-734-9908
Mailing address:
  • Phone: 302-734-3331
  • Fax: 302-734-9908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC20003111
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: