Provider Demographics
NPI:1740208404
Name:JALLOUL, AHMAD SOUHEIL (MD)
Entity Type:Individual
Prefix:
First Name:AHMAD
Middle Name:SOUHEIL
Last Name:JALLOUL
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:PO BOX 386
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-0386
Mailing Address - Country:US
Mailing Address - Phone:352-404-5986
Mailing Address - Fax:877-762-7377
Practice Address - Street 1:3121 CITRUS TOWER BLVD
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-6881
Practice Address - Country:US
Practice Address - Phone:352-404-5968
Practice Address - Fax:877-762-7377
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME97922207RS0012X, 207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL277784300Medicaid
FL277784300Medicaid
FLAC199Medicare PIN