Provider Demographics
NPI:1487612727
Name:GHANEM DAGHESTANI MD PA
Entity type:Organization
Organization Name:GHANEM DAGHESTANI MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GHANEM
Authorized Official - Middle Name:
Authorized Official - Last Name:DAGHESTANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-542-8400
Mailing Address - Street 1:PO BOX 1348
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78540-1348
Mailing Address - Country:US
Mailing Address - Phone:956-687-4600
Mailing Address - Fax:956-631-4555
Practice Address - Street 1:2717 MICHAEL ANGELO
Practice Address - Street 2:SUITE 303
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-1408
Practice Address - Country:US
Practice Address - Phone:956-687-4600
Practice Address - Fax:956-631-4555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00317438OtherRAILROAD
TX180265401Medicaid
TX00W475Medicare PIN