Provider Demographics
NPI:1578553434
Name:SALLAM, ENAS (MD)
Entity Type:Individual
Prefix:DR
First Name:ENAS
Middle Name:
Last Name:SALLAM
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:PO BOX 863407
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3407
Mailing Address - Country:US
Mailing Address - Phone:941-917-2600
Mailing Address - Fax:941-917-7884
Practice Address - Street 1:5350 UNIVERSITY PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243-5812
Practice Address - Country:US
Practice Address - Phone:941-917-4675
Practice Address - Fax:941-917-4688
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME79734208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL262470200Medicaid
FL51725OtherBCBS
FL51725OtherBCBS
FLH23153Medicare UPIN