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General NPI Number Information
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NPI Number | 1538664057
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Entity Type | Individual
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Provider Name | MOHAMMAD HISSOUROU III MD
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Gender | Male
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Dates
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Enumeration Date | 03/27/2018
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Last Update Date | 06/06/2023
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Provider Practice Location Address
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Address Line | 808 SW CAMPUS DR
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City | PORTLAND
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State | OR
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Zip | 97239-3008
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Country | US
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Telephone | 503-494-8756
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Fax |
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Provider Business Mailing Address
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Address Line | 1900 NW MYHRE RD
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City | SILVERDALE
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State | WA
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Zip | 98383-7662
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Country | US
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Telephone | 564-240-3100
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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 | 2085R0001X
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Taxonomy Name | Radiation Oncology Physician
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License Number | MD209773
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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