Provider Demographics
NPI:1154361004
Name:AL-SHAER, MOUTASIM HOMOD (M D)
Entity type:Individual
Prefix:DR
First Name:MOUTASIM
Middle Name:HOMOD
Last Name:AL-SHAER
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10501 E 91ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-5790
Mailing Address - Country:US
Mailing Address - Phone:918-502-1900
Mailing Address - Fax:918-494-6303
Practice Address - Street 1:6600 S YALE AVE
Practice Address - Street 2:SUITE 1400
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3347
Practice Address - Country:US
Practice Address - Phone:918-488-6001
Practice Address - Fax:918-488-6010
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK26873208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IACD1018OtherRAILROAD MEDICARE
IA1239726OtherCONTROLLED SUBSTANCE REG.
OK20024424DAMedicaid
OKOK403198Medicare PIN
IA1239726OtherCONTROLLED SUBSTANCE REG.