Provider Demographics
NPI:1306820618
Name:DABOUL, ISAM (MD)
Entity Type:Individual
Prefix:DR
First Name:ISAM
Middle Name:
Last Name:DABOUL
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 1:2702 NAVARRE AVENUE
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:OH
Mailing Address - Zip Code:43616-3224
Mailing Address - Country:US
Mailing Address - Phone:419-696-5555
Mailing Address - Fax:419-696-8499
Practice Address - Street 1:2702 NAVARRE AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-3223
Practice Address - Country:US
Practice Address - Phone:419-383-3742
Practice Address - Fax:419-383-6244
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35079506207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2250424Medicaid
OH2250424Medicaid