1659312098 NPI number — MR. SAMUEL ISSAM MALLOUHI MD

Table of content: MR. SAMUEL ISSAM MALLOUHI MD (NPI 1659312098)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659312098 NPI number — MR. SAMUEL ISSAM MALLOUHI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALLOUHI
Provider First Name:
SAMUEL
Provider Middle Name:
ISSAM
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MALLOUHI
Provider Other First Name:
ISSAM
Provider Other Middle Name:
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1659312098
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1031 MCBRIDE AVE
Provider Second Line Business Mailing Address:
SUITE D205
Provider Business Mailing Address City Name:
WOODLAND PARK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07424-2559
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-237-9055
Provider Business Mailing Address Fax Number:
973-237-9053

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1031 MCBRIDE AVE
Provider Second Line Business Practice Location Address:
SUITE D205
Provider Business Practice Location Address City Name:
WOODLAND PARK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07424-2559
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-237-9055
Provider Business Practice Location Address Fax Number:
973-237-9053
Provider Enumeration Date:
06/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  MA61762 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: MA061762 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7726201 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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