Provider Demographics
NPI:1104884584
Name:SOUSSOU, ISSAM D (MD)
Entity type:Individual
Prefix:
First Name:ISSAM
Middle Name:D
Last Name:SOUSSOU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3333 CATTLEMEN RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232-6056
Mailing Address - Country:US
Mailing Address - Phone:941-341-0042
Mailing Address - Fax:941-342-3432
Practice Address - Street 1:3333 CATTLEMEN RD
Practice Address - Street 2:SUITE 206
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34232-6056
Practice Address - Country:US
Practice Address - Phone:941-341-0042
Practice Address - Fax:941-342-3432
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME356362086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL38756800Medicaid
FL38756800Medicaid
FL79509ZMedicare PIN