Provider Demographics
NPI:1275530396
Name:SHEHATA, GEORGE W (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:W
Last Name:SHEHATA
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:PO BOX 967
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-0967
Mailing Address - Country:US
Mailing Address - Phone:708-532-6029
Mailing Address - Fax:708-532-6095
Practice Address - Street 1:3310 S OCEAN BLVD APT 427D
Practice Address - Street 2:
Practice Address - City:HIGHLAND BEACH
Practice Address - State:FL
Practice Address - Zip Code:33487-4798
Practice Address - Country:US
Practice Address - Phone:708-691-9823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036071862207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036071862Medicaid
IL036071862Medicaid
E14964Medicare UPIN