Provider Demographics
NPI:1699305722
Name:KULLAB, SAMAR IMAD
Entity type:Individual
Prefix:
First Name:SAMAR
Middle Name:IMAD
Last Name:KULLAB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 W SURF ST STE 5100
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-7227
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:331 W SURF ST STE 5100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-7227
Practice Address - Country:US
Practice Address - Phone:630-986-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-16
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164007737133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered