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General NPI Number Information
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NPI Number | 1558770743
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Entity Type | Individual
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Provider Name | HAITAM MOHAMAD BUAISHA MD
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Gender | Male
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Dates
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Enumeration Date | 08/13/2014
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Last Update Date | 09/02/2025
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Provider Practice Location Address
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Address Line | 11104 PARKVIEW CIRCLE DR STE 310
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City | FORT WAYNE
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State | IN
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Zip | 46845-1733
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Country | US
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Telephone | 260-266-5230
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Fax | 260-458-5972
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Provider Business Mailing Address
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Address Line | 11109 PARKVIEW PLAZA DR # 117
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City | FORT WAYNE
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State | IN
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Zip | 46845-1701
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Country | US
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Telephone |
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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 | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 7174
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License Number State | NE
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Taxonomy #2
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 32530
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License Number State | NE
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Taxonomy #3
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 33345
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License Number State | WV
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Taxonomy #4
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 01096804A
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License Number State | IN
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