Provider Demographics
NPI:1326172248
Name:ISSAM F DAMALOUJI MD
Entity Type:Organization
Organization Name:ISSAM F DAMALOUJI MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AGENT OFC MGR
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-263-6638
Mailing Address - Street 1:PO BOX 3269
Mailing Address - Street 2:
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-2279
Mailing Address - Country:US
Mailing Address - Phone:410-263-6638
Mailing Address - Fax:410-268-6830
Practice Address - Street 1:135 W DARES BEACH RD
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-3119
Practice Address - Country:US
Practice Address - Phone:410-263-6638
Practice Address - Fax:410-268-6830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0003077207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD756MMedicare ID - Type UnspecifiedMEDICARE GROUP NUMBER