Provider Demographics
NPI:1588736714
Name:ITANI, ABDUL-RAHMAN YOUSSEF (DO)
Entity type:Individual
Prefix:
First Name:ABDUL-RAHMAN
Middle Name:YOUSSEF
Last Name:ITANI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1941
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034
Mailing Address - Country:US
Mailing Address - Phone:817-952-3050
Mailing Address - Fax:817-952-3053
Practice Address - Street 1:729 WEST BEDFORD - EULESS RD.
Practice Address - Street 2:SUITE 105
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76053
Practice Address - Country:US
Practice Address - Phone:817-952-3050
Practice Address - Fax:817-952-3053
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH8149207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133604207Medicaid
F58055Medicare UPIN
00248WMedicare PIN
TX133604207Medicaid