Healthcare Provider Details

I. General information

NPI: 1730177114
Provider Name (Legal Business Name): HUMAM BASSAM KAKISH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7515 GREENVILLE AVE STE 706
DALLAS TX
75231-3885
US

IV. Provider business mailing address

7515 GREENVILLE AVE STE 706
DALLAS TX
75231-3885
US

V. Phone/Fax

Practice location:
  • Phone: 469-547-1142
  • Fax: 469-547-1162
Mailing address:
  • Phone: 469-547-1142
  • Fax: 469-547-1162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberK0853
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: