Healthcare Provider Details

I. General information

NPI: 1912048703
Provider Name (Legal Business Name): HUSAM SROUR MALLAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 09/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5757 W THUNDERBIRD RD STE W310
GLENDALE AZ
85306-4644
US

IV. Provider business mailing address

5757 W THUNDERBIRD RD STE W310
GLENDALE AZ
85306-4644
US

V. Phone/Fax

Practice location:
  • Phone: 602-865-4011
  • Fax: 602-865-4250
Mailing address:
  • Phone: 602-865-4011
  • Fax: 602-865-4250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01067525A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number01067525A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: