Individual
DR. HAROLD MUSTAPHA BACCHUS JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1719 CREMER AVE, FORT WAYNE, IN 46818-1052
(260) 490-9150
(260) 490-9195
Mailing address
12002 WOODBOURNE CT, FT WAYNE, IN 46845-1952
(260) 637-5303
(260) 490-9195
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
01034833
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000634416
ANTHEM
IN
05
—
200027190
—
IN
Enumeration date
03/25/2006
Last updated
12/20/2009
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