Provider Demographics
NPI:1457417040
Name:SALLOUM, RAFAH (MD)
Entity Type:Individual
Prefix:DR
First Name:RAFAH
Middle Name:
Last Name:SALLOUM
Suffix:
Gender:F
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 281
Mailing Address - Street 2:
Mailing Address - City:COLTS NECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07722-0281
Mailing Address - Country:US
Mailing Address - Phone:732-414-6001
Mailing Address - Fax:732-431-6003
Practice Address - Street 1:219 TAYLORS MILLS RD
Practice Address - Street 2:
Practice Address - City:MANALAPAN
Practice Address - State:NJ
Practice Address - Zip Code:07726-3255
Practice Address - Country:US
Practice Address - Phone:732-414-6001
Practice Address - Fax:732-414-6003
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08174300207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001408914Medicaid
CT110008697Medicare ID - Type UnspecifiedPROVIDER NUMBER
CT32579OtherCT CSR
CTBS7996323OtherFED DEA
CT040891OtherCT PHYSICIAN LICENSE
CTH72098Medicare UPIN