Provider Demographics
NPI:1225383417
Name:MJALTAJ, MARIOLA (MD)
Entity Type:Individual
Prefix:
First Name:MARIOLA
Middle Name:
Last Name:MJALTAJ
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 1:17183 I H 45 S STE 550
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77385-3314
Mailing Address - Country:US
Mailing Address - Phone:936-270-3800
Mailing Address - Fax:
Practice Address - Street 1:17183 I H 45 S STE 550
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77385
Practice Address - Country:US
Practice Address - Phone:936-270-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-13
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.130630207Q00000X
TXR3155207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.130630OtherLICENSE