Provider Demographics
NPI:1881621118
Name:JIFI-BAHLOOL, SAMER IZZAT (MD)
Entity type:Individual
Prefix:MR
First Name:SAMER
Middle Name:IZZAT
Last Name:JIFI-BAHLOOL
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:PO BOX 60041
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78466-0041
Mailing Address - Country:US
Mailing Address - Phone:361-882-9278
Mailing Address - Fax:
Practice Address - Street 1:614 FURMAN AVE
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-2325
Practice Address - Country:US
Practice Address - Phone:361-882-9278
Practice Address - Fax:361-882-9279
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0304207RN0300X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX74-2617515OtherTAX ID
TX046256601Medicaid
TX74-2617515OtherTAX ID
TX046256601Medicaid