Provider Demographics
NPI:1144840463
Name:MOALLIN, BASHIR (MBBS)
Entity type:Individual
Prefix:DR
First Name:BASHIR
Middle Name:
Last Name:MOALLIN
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3405 3RD ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-4015
Mailing Address - Country:US
Mailing Address - Phone:320-774-1041
Mailing Address - Fax:320-774-1049
Practice Address - Street 1:1555 NORTHWAY DR STE 200
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4913
Practice Address - Country:US
Practice Address - Phone:320-240-3157
Practice Address - Fax:320-240-3164
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-17
Last Update Date:2024-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN70813207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program