Healthcare Provider Details

I. General information

NPI: 1104884584
Provider Name (Legal Business Name): ISSAM D SOUSSOU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 05/07/2020
Certification Date: 05/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 CATTLEMEN RD SUITE 206
SARASOTA FL
34232-6056
US

IV. Provider business mailing address

3333 CATTLEMEN RD SUITE 206
SARASOTA FL
34232-6056
US

V. Phone/Fax

Practice location:
  • Phone: 941-341-0042
  • Fax: 941-342-3432
Mailing address:
  • Phone: 941-341-0042
  • Fax: 941-342-3432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberME35636
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: