Provider Demographics
NPI:1306862479
Name:HALLOUM, JIHAD (MD)
Entity type:Individual
Prefix:
First Name:JIHAD
Middle Name:
Last Name:HALLOUM
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 1:2074 E SOUTHERN AVE STE B101
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-7534
Mailing Address - Country:US
Mailing Address - Phone:480-839-1032
Mailing Address - Fax:480-838-7147
Practice Address - Street 1:2074 E SOUTHERN AVE STE B101
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7534
Practice Address - Country:US
Practice Address - Phone:480-839-1032
Practice Address - Fax:480-838-7147
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35679207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00405605OtherRAILROAD MEDICARE
AZ169772Medicaid
AZZ112954Medicare PIN
AZI68343Medicare UPIN