Provider Demographics
NPI:1114451523
Name:TABISH, SHAKEEL AHMAD
Entity Type:Individual
Prefix:
First Name:SHAKEEL
Middle Name:AHMAD
Last Name:TABISH
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:PO BOX 5010
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58702-5010
Mailing Address - Country:US
Mailing Address - Phone:701-418-8000
Mailing Address - Fax:
Practice Address - Street 1:2305 37TH AVE SW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-7669
Practice Address - Country:US
Practice Address - Phone:701-857-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2021-011922084N0400X
SC887142084S0012X
NDPT197252084S0012X
ND197252084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPENDINGMedicaid