Provider Demographics
NPI:1154371078
Name:BISMAR, HISHAM (MD)
Entity type:Individual
Prefix:DR
First Name:HISHAM
Middle Name:
Last Name:BISMAR
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 1:11807 SOUTH FREEWAY, STE 362
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76115
Mailing Address - Country:US
Mailing Address - Phone:817-568-0004
Mailing Address - Fax:817-568-0804
Practice Address - Street 1:11807 SOUTH FREEWAY, STE 362
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76115
Practice Address - Country:US
Practice Address - Phone:817-568-0004
Practice Address - Fax:817-568-0804
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4873207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX139031213Medicaid
80330FMedicare ID - Type Unspecified
A78590Medicare UPIN