MEDICARE: DR. GHADA K KASSAB M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	A114457	CA
2	207N00000X	Dermatology Physician	11013338A	IN
3	207N00000X	Dermatology Physician	01069398A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000720044	OTHER	IN	ANTHEM PROVIDER NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023278504
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GHADA K KASSAB M.D.

Provider Business Mailing Address
First Line	:	4606 MISSION BAY DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-4921
Country	:	US
Telephone Number	:	858-273-2726
Fax Number	:	858-273-2725

Provider Business Practice Location Address
First Line	:	4606 MISSION BAY DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-4921
Country	:	US
Telephone Number	:	858-273-2726
Fax Number	:	858-273-2725

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2008
Last Update Date	:	05/01/2024

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