Provider Demographics
NPI:1033115076
Name:JALALI, HAMID R (DO)
Entity Type:Individual
Prefix:
First Name:HAMID
Middle Name:R
Last Name:JALALI
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:PO BOX 966
Mailing Address - Street 2:
Mailing Address - City:MAURICEVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77626-0966
Mailing Address - Country:US
Mailing Address - Phone:409-745-4421
Mailing Address - Fax:409-745-4426
Practice Address - Street 1:11946 HIGHWAY 62 N
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:TX
Practice Address - Zip Code:77632-4004
Practice Address - Country:US
Practice Address - Phone:409-745-4421
Practice Address - Fax:409-745-4426
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2014-07-18
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-21
Provider Licenses
StateLicense IDTaxonomies
TXH0491207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX122951002Medicaid
TX122951002Medicaid
TXA67172Medicare UPIN