Provider Demographics
NPI:1447466016
Name:DALLOUL, GHASSAN (MD)
Entity type:Individual
Prefix:
First Name:GHASSAN
Middle Name:
Last Name:DALLOUL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 182005
Mailing Address - Street 2:
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48318-2005
Mailing Address - Country:US
Mailing Address - Phone:248-878-3171
Mailing Address - Fax:248-928-0916
Practice Address - Street 1:37799 PROFESSIONAL CENTER DR STE 105
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-1123
Practice Address - Country:US
Practice Address - Phone:248-878-3171
Practice Address - Fax:248-928-0916
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301087543207RI0011X
AZ47872207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
4301087543OtherSTATE LICENSE
MI1447466016Medicaid
AZ817692Medicaid