Provider Demographics
NPI:1659312098
Name:MALLOUHI, SAMUEL ISSAM (MD)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:ISSAM
Last Name:MALLOUHI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:ISSAM
Other - Middle Name:
Other - Last Name:MALLOUHI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1031 MCBRIDE AVE
Mailing Address - Street 2:SUITE D205
Mailing Address - City:WOODLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07424-2559
Mailing Address - Country:US
Mailing Address - Phone:973-237-9055
Mailing Address - Fax:973-237-9053
Practice Address - Street 1:1031 MCBRIDE AVE
Practice Address - Street 2:SUITE D205
Practice Address - City:WOODLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:07424-2559
Practice Address - Country:US
Practice Address - Phone:973-237-9055
Practice Address - Fax:973-237-9053
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA61762207P00000X
NJMA061762207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7726201Medicaid
NJ7726201Medicaid