Provider Demographics
NPI:1225125610
Name:TRABOULSI, AMMAR S (MD)
Entity Type:Individual
Prefix:DR
First Name:AMMAR
Middle Name:S
Last Name:TRABOULSI
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 1:495 GOLD STAR HWY STE 224
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-6230
Mailing Address - Country:US
Mailing Address - Phone:860-326-5405
Mailing Address - Fax:860-326-5571
Practice Address - Street 1:41 FAIR HARBOUR PL
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4710
Practice Address - Country:US
Practice Address - Phone:860-437-6914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0416922084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTBT8481361OtherDEA REGISTRATION NUMBER
CTH93205Medicare UPIN