Provider Demographics
NPI:1659303659
Name:SALLOUM, ANTOINE (MD)
Entity Type:Individual
Prefix:
First Name:ANTOINE
Middle Name:
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 1:1500 NW 12TH AVE
Mailing Address - Street 2:JMT-EAST 1007
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1028
Mailing Address - Country:US
Mailing Address - Phone:305-243-4664
Mailing Address - Fax:305-243-8470
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:BOX 016960 M851
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-585-1111
Practice Address - Fax:305-243-8470
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME59063207RC0000X
FLME0059063207RI0001X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical & Laboratory Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0522708-00Medicaid
FL3032337-00Medicaid
FL0522708-00Medicaid
12106Medicare ID - Type Unspecified