Provider Demographics
NPI:1316910912
Name:DALLOUL, ELIAS A (MD)
Entity type:Individual
Prefix:DR
First Name:ELIAS
Middle Name:A
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 1:2723 S 7TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-3558
Mailing Address - Country:US
Mailing Address - Phone:812-238-1730
Mailing Address - Fax:812-242-1565
Practice Address - Street 1:2723 S 7TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-3558
Practice Address - Country:US
Practice Address - Phone:812-232-8164
Practice Address - Fax:812-234-6391
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01055767A207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200378660Medicaid
IN000000220344OtherANTHEM PIN
IN060067299OtherRAILROAD MEDICARE
IN100778OtherFEDERAL BLACK LUNG
IN200378660Medicaid
IN000000220344OtherANTHEM PIN
IN941090R2Medicare PIN