Provider Demographics
NPI:1194869941
Name:BASHIOUM, RALPH W (MD)
Entity type:Individual
Prefix:DR
First Name:RALPH
Middle Name:W
Last Name:BASHIOUM
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 1:461 PEAVEY LN
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-1534
Mailing Address - Country:US
Mailing Address - Phone:952-743-7854
Mailing Address - Fax:
Practice Address - Street 1:445 LAKE ST E
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-1657
Practice Address - Country:US
Practice Address - Phone:952-449-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30397208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery