Provider Demographics
NPI:1649314972
Name:LOUIS, MARIAM (MD)
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:LOUIS
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 44008
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-244-3071
Mailing Address - Fax:904-244-5090
Practice Address - Street 1:655 W 8TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-244-3071
Practice Address - Fax:904-244-5090
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD12529207RS0012X, 207RP1001X
FLME117644207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009924900Medicaid
GA003139985AMedicaid
FL14S8VOtherBCBS
GA003139985AMedicaid