Provider Demographics
NPI:1457456881
Name:DALATI, GHASSAN (MD)
Entity Type:Individual
Prefix:
First Name:GHASSAN
Middle Name:
Last Name:DALATI
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 1:101 E BRUNSON ST STE 110
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-2500
Mailing Address - Country:US
Mailing Address - Phone:334-348-4278
Mailing Address - Fax:334-348-8883
Practice Address - Street 1:101 E BRUNSON ST STE 110
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2500
Practice Address - Country:US
Practice Address - Phone:334-348-4278
Practice Address - Fax:334-348-8883
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39041207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00431665OtherRAILROAD
KY000000547852OtherBCBS
WV3810014609Medicaid
KY64098650Medicaid
WV3810014609Medicaid
KY64098650Medicaid
KYI31098Medicare UPIN