Provider Demographics
NPI:1124176151
Name:SALLOUM, ALEXANDER CHARLES (MD)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:CHARLES
Last Name:SALLOUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SASHA
Other - Middle Name:ALEXANDER
Other - Last Name:SALLOUM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1111 BROADWAY STE 305
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-2700
Mailing Address - Country:US
Mailing Address - Phone:619-567-7007
Mailing Address - Fax:619-567-7775
Practice Address - Street 1:1111 BROADWAY STE 305
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911
Practice Address - Country:US
Practice Address - Phone:619-567-7007
Practice Address - Fax:619-567-7775
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA893002085R0204X, 208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1124176151Medicaid
CA1124176151Medicaid