Healthcare Provider Details

I. General information

NPI: 1356344287
Provider Name (Legal Business Name): GHASOUB HARB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 09/29/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3319 SPRING STREET UROLOGICAL ASSC PC
DAVENPORT IA
52807
US

IV. Provider business mailing address

3319 SPRING STREET
DAVENPORT IA
52807
US

V. Phone/Fax

Practice location:
  • Phone: 563-359-1641
  • Fax: 563-359-4634
Mailing address:
  • Phone: 563-359-1641
  • Fax: 563-359-4634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036093919
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number31158
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: