Provider Demographics
NPI:1174507537
Name:NAMAK, SHAHLA Y (MD)
Entity Type:Individual
Prefix:
First Name:SHAHLA
Middle Name:Y
Last Name:NAMAK
Suffix:
Gender:F
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:PO BOX 602658
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2658
Mailing Address - Country:US
Mailing Address - Phone:336-716-2011
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-4479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200501629207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC807294OtherPARTNERS
NC1404YOtherBCBS
SCQ01629Medicaid
NC183716OtherMEDCOST
WV3810003636Medicaid
7925722OtherAETNA
VA10208521Medicaid
NC5902281Medicaid
NC5902281Medicaid