Provider Demographics
NPI:1760457147
Name:SALLOUM, IHSAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:IHSAN
Middle Name:M
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 1:2102 TREASURE HILLS BLVD STE 2.126
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550-8736
Mailing Address - Country:US
Mailing Address - Phone:956-296-5527
Mailing Address - Fax:
Practice Address - Street 1:2902 HAINE DRIVE
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550
Practice Address - Country:US
Practice Address - Phone:956-296-4000
Practice Address - Fax:956-296-2842
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME988602084P0800X
TXS67312084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001179664Medicaid
TX4306227-01Medicaid
TXBCBSOtherH08QJ49601