Provider Demographics
NPI:1427785229
Name:ATALLAH, SHADI
Entity type:Individual
Prefix:
First Name:SHADI
Middle Name:
Last Name:ATALLAH
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 1:6906 ARGONNE FOREST CV # A
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-2202
Mailing Address - Country:US
Mailing Address - Phone:737-206-6386
Mailing Address - Fax:
Practice Address - Street 1:6906 ARGONNE FOREST CV # A
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-2202
Practice Address - Country:US
Practice Address - Phone:737-206-6386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty