Provider Demographics
NPI:1790455095
Name:ABU-MALLOUH, THARA (OD)
Entity Type:Individual
Prefix:
First Name:THARA
Middle Name:
Last Name:ABU-MALLOUH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7205 BENTLEY RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7565
Mailing Address - Country:US
Mailing Address - Phone:904-296-0098
Mailing Address - Fax:904-861-3899
Practice Address - Street 1:7205 BENTLEY RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7565
Practice Address - Country:US
Practice Address - Phone:904-296-0098
Practice Address - Fax:904-861-3899
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC6013152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty