Healthcare Provider Details

I. General information

NPI: 1881621118
Provider Name (Legal Business Name): SAMER IZZAT JIFI-BAHLOOL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 09/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 FURMAN AVE
CORPUS CHRISTI TX
78404-2325
US

IV. Provider business mailing address

PO BOX 60041
CORPUS CHRISTI TX
78466-0041
US

V. Phone/Fax

Practice location:
  • Phone: 361-882-9278
  • Fax: 361-882-9279
Mailing address:
  • Phone: 361-882-9278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberL0304
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberL0304
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: