Provider Demographics
NPI:1154148807
Name:NELSON, SHIHATA
Entity type:Individual
Prefix:MR
First Name:SHIHATA
Middle Name:
Last Name:NELSON
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 1:18630 WASHBURN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-1916
Mailing Address - Country:US
Mailing Address - Phone:313-231-0829
Mailing Address - Fax:313-862-3288
Practice Address - Street 1:18630 WASHBURN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-1916
Practice Address - Country:US
Practice Address - Phone:313-231-0829
Practice Address - Fax:313-862-3288
Is Sole Proprietor?:No
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI801265656172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver