Healthcare Provider Details

I. General information

NPI: 1225094188
Provider Name (Legal Business Name): GABRIEL ELLIS SALLOUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 06/11/2020
Certification Date: 06/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4308 ALTON RD STE 940
MIAMI BEACH FL
33140-4560
US

IV. Provider business mailing address

4308 ALTON RD STE 720
MIAMI FL
33140-4557
US

V. Phone/Fax

Practice location:
  • Phone: 305-405-6910
  • Fax: 305-405-6912
Mailing address:
  • Phone: 305-405-6910
  • Fax: 305-405-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberME81572
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: