Healthcare Provider Details

I. General information

NPI: 1275283939
Provider Name (Legal Business Name): DANNY BASEL GHANNOUM DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2022
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 WALNUT AVE SW
ROANOKE VA
24016-4723
US

IV. Provider business mailing address

PO BOX 825159
PHILADELPHIA PA
19182-5159
US

V. Phone/Fax

Practice location:
  • Phone: 540-344-3668
  • Fax: 540-774-4615
Mailing address:
  • Phone: 866-626-1540
  • Fax: 866-386-8526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPENDING
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: