Provider Demographics
NPI:1629016159
Name:MOSTAFA ELSAWY, BASSEM MORAD (MD, CMD, AGSF, FAAFP)
Entity type:Individual
Prefix:DR
First Name:BASSEM
Middle Name:MORAD
Last Name:MOSTAFA ELSAWY
Suffix:
Gender:M
Credentials:MD, CMD, AGSF, FAAFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 W WHEATLAND RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237-3460
Mailing Address - Country:US
Mailing Address - Phone:214-947-5400
Mailing Address - Fax:
Practice Address - Street 1:3500 W WHEATLAND RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-3460
Practice Address - Country:US
Practice Address - Phone:214-947-5400
Practice Address - Fax:214-947-5425
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4379207QG0300X, 207QH0002X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200453380Medicaid
TX75-2966610OtherFEIN
TX182868301Medicaid
TX156122701Medicaid
TX156122702Medicaid
TX156122702Medicaid
TX182868301Medicaid
IN200453380Medicaid
TX8G7576Medicare PIN