Provider Demographics
NPI:1427673839
Name:SALLOUT, OMAR
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:SALLOUT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4430 N HOLLAND SYLVANIA RD APT 4213
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-3554
Mailing Address - Country:US
Mailing Address - Phone:567-420-4510
Mailing Address - Fax:
Practice Address - Street 1:4430 N HOLLAND SYLVANIA RD APT 4213
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-3554
Practice Address - Country:US
Practice Address - Phone:567-420-4510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-11
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.250215208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery