Healthcare Provider Details

I. General information

NPI: 1669000972
Provider Name (Legal Business Name): ANAS AHMAD DALLOUL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 07/26/2025
Certification Date: 07/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 WOODLAND ST
HARTFORD CT
06105-1208
US

IV. Provider business mailing address

9975 NW 7TH ST
PLANTATION FL
33324-4908
US

V. Phone/Fax

Practice location:
  • Phone: 860-714-6654
  • Fax:
Mailing address:
  • Phone: 954-401-0339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberOS22456
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number81723
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: