Healthcare Provider Details

I. General information

NPI: 1326172248
Provider Name (Legal Business Name): ISSAM F DAMALOUJI MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 W DARES BEACH RD
PRINCE FREDERICK MD
20678-3119
US

IV. Provider business mailing address

PO BOX 3269
PRINCE FREDERICK MD
20678-2279
US

V. Phone/Fax

Practice location:
  • Phone: 410-263-6638
  • Fax: 410-268-6830
Mailing address:
  • Phone: 410-263-6638
  • Fax: 410-268-6830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0003077
License Number StateMD

VIII. Authorized Official

Name: TRACEY L HAYNES
Title or Position: BILLING AGENT OFC MGR
Credential:
Phone: 410-263-6638