Healthcare Provider Details

I. General information

NPI: 1154565661
Provider Name (Legal Business Name): BISHR AL DABAGH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2009
Last Update Date: 01/02/2024
Certification Date: 01/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 GATEWAY BLVD STE A
MOORESVILLE NC
28117-6542
US

IV. Provider business mailing address

118 GATEWAY BLVD STE A
MOORESVILLE NC
28117-6542
US

V. Phone/Fax

Practice location:
  • Phone: 704-230-1302
  • Fax:
Mailing address:
  • Phone: 704-230-1302
  • Fax: 704-230-1284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number4301106561
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD17679
License Number StateHI
# 3
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberMD17679
License Number StateHI
# 4
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberME142263
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number4301106561
License Number StateMI
# 6
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number49483
License Number StateAZ
# 7
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberA125540
License Number StateCA
# 8
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number2019-01570
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: