Healthcare Provider Details

I. General information

NPI: 1669046645
Provider Name (Legal Business Name): LAITH ABUSHANAB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2021
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 E CHEROKEE ST
SPRINGFIELD MO
65804-2203
US

IV. Provider business mailing address

82 SMITHTOWN RD
BUDD LAKE NJ
07828-1932
US

V. Phone/Fax

Practice location:
  • Phone: 417-820-9857
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number2024014340
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: