Provider Demographics
NPI:1023004710
Name:ABOU ASSI, SOUHEIL GHANDOUR (MD)
Entity Type:Individual
Prefix:
First Name:SOUHEIL
Middle Name:GHANDOUR
Last Name:ABOU ASSI
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 1:2369 STAPLES MILL RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-2918
Mailing Address - Country:US
Mailing Address - Phone:804-285-4465
Mailing Address - Fax:804-285-8332
Practice Address - Street 1:6602 W BROAD ST STE B
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-1702
Practice Address - Country:US
Practice Address - Phone:804-285-8206
Practice Address - Fax:804-288-6602
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101058695207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1100088459Medicaid
VA5831938Medicare ID - Type Unspecified
VA1100088459Medicaid