Provider Demographics
NPI:1770547259
Name:DABOUL, NIZAR Y (MD)
Entity type:Individual
Prefix:DR
First Name:NIZAR
Middle Name:Y
Last Name:DABOUL
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 1:6450 WHEATSTONE CT
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-9402
Mailing Address - Country:US
Mailing Address - Phone:419-866-6200
Mailing Address - Fax:419-866-7170
Practice Address - Street 1:6450 WHEATSTONE CT
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-9402
Practice Address - Country:US
Practice Address - Phone:419-866-6200
Practice Address - Fax:419-866-7170
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35072198207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2008562Medicaid
OH2008562Medicaid
OHH314910Medicare PIN