Provider Demographics
NPI:1225094188
Name:SALLOUM, GABRIEL ELLIS (MD)
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:ELLIS
Last Name:SALLOUM
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 1:4308 ALTON RD STE 720
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33140-4557
Mailing Address - Country:US
Mailing Address - Phone:305-405-6910
Mailing Address - Fax:305-405-6912
Practice Address - Street 1:4308 ALTON RD
Practice Address - Street 2:STE 940
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140-4560
Practice Address - Country:US
Practice Address - Phone:305-405-6910
Practice Address - Fax:305-405-6912
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81572173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI72287Medicare UPIN