Provider Demographics
NPI:1669000972
Name:DALLOUL, ANAS AHMAD
Entity Type:Individual
Prefix:
First Name:ANAS
Middle Name:AHMAD
Last Name:DALLOUL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9975 NW 7TH ST
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-4908
Mailing Address - Country:US
Mailing Address - Phone:954-401-0339
Mailing Address - Fax:
Practice Address - Street 1:2001 KINGSLEY AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5156
Practice Address - Country:US
Practice Address - Phone:904-639-2002
Practice Address - Fax:904-639-2015
Is Sole Proprietor?:No
Enumeration Date:2020-03-31
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program