Provider Demographics
NPI:1962998765
Name:DERBAL, OUASSIM (MD)
Entity type:Individual
Prefix:
First Name:OUASSIM
Middle Name:
Last Name:DERBAL
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 1:17303 MUSSELBURGH DR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-6976
Mailing Address - Country:US
Mailing Address - Phone:305-318-8522
Mailing Address - Fax:
Practice Address - Street 1:250 SMITH CHURCH RD
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-4914
Practice Address - Country:US
Practice Address - Phone:252-535-8011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC239615390200000X
390200000X
NC2021-01829207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program