Provider Demographics
NPI:1134652449
Name:GHANNAM, SARA MARIAM (MD)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:MARIAM
Last Name:GHANNAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 E 12TH ST
Mailing Address - Street 2:APT 14Q
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44114-3207
Mailing Address - Country:US
Mailing Address - Phone:734-846-3651
Mailing Address - Fax:
Practice Address - Street 1:9500 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-0001
Practice Address - Country:US
Practice Address - Phone:216-444-2200
Practice Address - Fax:216-636-0110
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-05
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA11461800207K00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology