Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | 2009010810 | MO |
N | 111NI0900X | Internist | 2009010810 | MO |
N | 207R00000X | Internist | ME121864 | FL |
N | 111NI0900X | Internist | ME121864 | FL |
N | 207RG0300X | Geriatric Medicine | 4301102046 | MI |
Y | 207U00000X | Nuclear Medicine Specialist | ME121864 | FL |
NPI | 1134359599 |
---|---|
Provider Name | Imad Abossallue |
First Address | Lafayette, LA 70508-3870 |
Second Address | Miami, FL 33136-1005 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/07/2009 |
Last Update Date | 06/12/2019 |