Basic Information
Provider Information | |||||||||
NPI: | 1003926973 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HUSAYN | ||||||||
FirstName: | FAROOQ | ||||||||
MiddleName: | JAMEEL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HUSSAIN | ||||||||
OtherFirstName: | FAROOQ | ||||||||
OtherMiddleName: | JAMEEL | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 277 BUDDY GANEM DR STE A | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | TX | ||||||||
PostalCode: | 783743202 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3617773900 | ||||||||
FaxNumber: | 3614130274 | ||||||||
Practice Location | |||||||||
Address1: | 277 BUDDY GANEM DR STE A | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | TX | ||||||||
PostalCode: | 783743202 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3617773900 | ||||||||
FaxNumber: | 3614130274 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/30/2006 | ||||||||
LastUpdateDate: | 03/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/08/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | S7242 | TX | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 430040201 | 05 | TX |   | MEDICAID |