Basic Information
| Provider Information | |||||||||
| NPI: | 1609829639 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BISHARA | ||||||||
| FirstName: | HAYTHAM | ||||||||
| MiddleName: | B. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1891 | ||||||||
| Address2: | |||||||||
| City: | MANY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 714491891 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3185901301 | ||||||||
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| Practice Location | |||||||||
| Address1: | 240 HIGHLAND DR | ||||||||
| Address2: | |||||||||
| City: | MANY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 714493718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182565691 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 13078R | LA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 1553573 | 05 | LA | MEDICAID |