Healthcare Provider Details

I. General information

NPI: 1811973530
Provider Name (Legal Business Name): MAHMOUD F HASSUNEH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 N MADISON AVE
ANDERSON IN
46011-3453
US

IV. Provider business mailing address

6626 E 75TH ST SUITE 500
INDIANAPOLIS IN
46250-2805
US

V. Phone/Fax

Practice location:
  • Phone: 765-298-4242
  • Fax: 317-355-8734
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01045596
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: