Provider Demographics
NPI:1083693634
Name:GADALLA, ALY A (MD)
Entity Type:Individual
Prefix:DR
First Name:ALY
Middle Name:A
Last Name:GADALLA
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 1:1861 N ROCK RD STE 100
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-1264
Mailing Address - Country:US
Mailing Address - Phone:316-462-1070
Mailing Address - Fax:316-462-1078
Practice Address - Street 1:1861 N ROCK RD STE 100
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-1264
Practice Address - Country:US
Practice Address - Phone:316-462-1070
Practice Address - Fax:316-462-1078
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-29832207R00000X
KS0429832207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100640650SMedicaid
KSKA2755001Medicare PIN
KSKA1398020Medicare PIN
KS100640650MMedicaid
KSKA1000028Medicare PIN
KSKA2473010Medicare PIN
KSKA1092004Medicare PIN