Healthcare Provider Details

I. General information

NPI: 1295721678
Provider Name (Legal Business Name): ADDI S ABUELSHAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 08/19/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E PECAN JCMH/ HOSPITALIST OFFICE
ALTUS OK
73521
US

IV. Provider business mailing address

1200 E PECAN JCMH/ HOSPITALIST OFFICE
ALTUS OK
73521
US

V. Phone/Fax

Practice location:
  • Phone: 580-379-5992
  • Fax: 580-379-5999
Mailing address:
  • Phone: 580-379-5992
  • Fax: 580-379-5999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20057
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: