Healthcare Provider Details

I. General information

NPI: 1720645310
Provider Name (Legal Business Name): AHMAD ABOU YASSINE M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2019
Last Update Date: 06/28/2026
Certification Date: 06/28/2026
Deactivation Date: 01/17/2020
Reactivation Date: 02/19/2020

III. Provider practice location address

GASTROENTEROLOGY 1100 LEAD AVE SE
ALBUQUERQUE NM
87106-5215
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-224-7000
  • Fax: 505-224-7292
Mailing address:
  • Phone: 505-224-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD2015-0851
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: