Provider Demographics
NPI:1861412223
Name:SALIBA, BASSAM C (MD)
Entity type:Individual
Prefix:DR
First Name:BASSAM
Middle Name:C
Last Name:SALIBA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3106 NW ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-6123
Mailing Address - Country:US
Mailing Address - Phone:580-250-4278
Mailing Address - Fax:
Practice Address - Street 1:3106 NW ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-6123
Practice Address - Country:US
Practice Address - Phone:580-250-4278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21792207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100004250BMedicaid
OK100004250BMedicaid
OK248534007Medicare ID - Type Unspecified