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General NPI Number Information
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NPI Number | 1063354280
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Entity Type | Individual
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Provider Name | JACOB OMAR KHOUSSINE MD, PHD
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Gender | Male
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Dates
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Enumeration Date | 04/07/2026
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Last Update Date | 04/07/2026
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Provider Practice Location Address
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Address Line | 22 BRAMHALL ST
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City | PORTLAND
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State | ME
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Zip | 04102-3175
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Country | US
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Telephone | 207-662-7068
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Fax |
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Provider Business Mailing Address
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Address Line | 4620 FREY ST APT 115
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City | MADISON
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State | WI
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Zip | 53705-2903
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Country | US
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Telephone | 405-808-6005
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | EC261086
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License Number State | ME
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