Provider Demographics
NPI:1912079609
Name:MAALOULI, WALID (MD)
Entity type:Individual
Prefix:DR
First Name:WALID
Middle Name:
Last Name:MAALOULI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3652 ROBIN LN
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-1156
Mailing Address - Country:US
Mailing Address - Phone:516-485-1591
Mailing Address - Fax:651-493-7471
Practice Address - Street 1:2450 RIVERSIDE AVE # AO-301
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1450
Practice Address - Country:US
Practice Address - Phone:612-626-5451
Practice Address - Fax:612-626-1144
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN432012080A0000X
IL0360896392080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNF95797Medicare UPIN