Provider Demographics
NPI:1396780243
Name:NSOULI, IMAD S (MD)
Entity type:Individual
Prefix:
First Name:IMAD
Middle Name:S
Last Name:NSOULI
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 1:800 IRVING AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2716
Mailing Address - Country:US
Mailing Address - Phone:315-425-2636
Mailing Address - Fax:315-425-2639
Practice Address - Street 1:800 IRVING AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2716
Practice Address - Country:US
Practice Address - Phone:315-425-2636
Practice Address - Fax:315-425-2639
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY148367-1208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02891427Medicaid
NYJ400001974Medicare PIN