Healthcare Provider Details

I. General information

NPI: 1104888171
Provider Name (Legal Business Name): AFIF S HABASH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 05/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4920 MACCORKLE AVE SE
CHARLESTON WV
25304-2052
US

IV. Provider business mailing address

4920 MACCORKLE AVE SE
CHARLESTON WV
25304-2052
US

V. Phone/Fax

Practice location:
  • Phone: 304-442-8117
  • Fax:
Mailing address:
  • Phone: 304-925-1115
  • Fax: 304-925-1117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number10704
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: