Healthcare Provider Details

I. General information

NPI: 1740208404
Provider Name (Legal Business Name): AHMAD SOUHEIL JALLOUL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 02/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3121 CITRUS TOWER BLVD
CLERMONT FL
34711-6881
US

IV. Provider business mailing address

PO BOX 386
TAVARES FL
32778-0386
US

V. Phone/Fax

Practice location:
  • Phone: 352-404-5968
  • Fax: 877-762-7377
Mailing address:
  • Phone: 352-404-5986
  • Fax: 877-762-7377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberME97922
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberME97922
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberME97922
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: