Basic Information
| Provider Information | |||||||||
| NPI: | 1316923808 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOUSSAYER | ||||||||
| FirstName: | TAREK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 200993 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772160993 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2817841111 | ||||||||
| FaxNumber: | 2817841555 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 MEDIC LN | ||||||||
| Address2: | |||||||||
| City: | ALVIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775115542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813316141 | ||||||||
| FaxNumber: | 2813313316 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2005 | ||||||||
| LastUpdateDate: | 11/25/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | H9106 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8F9754 | 01 | TX | BCBS | OTHER | 8F9754 | 01 | TX | BCBSTX PROV NO | OTHER | 140302441 | 05 | TX | MEDICAID | 1316923808 | 01 | TX | TRICARE SOUTH | OTHER | 140302440 | 05 | TX | MEDICAID | 140302439 | 05 | TX | MEDICAID | 140302442 | 05 | TX | MEDICAID |