Provider Demographics
NPI:1558347187
Name:ATALLAH, NAJDAT (MD)
Entity Type:Individual
Prefix:
First Name:NAJDAT
Middle Name:
Last Name:ATALLAH
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 1:11312 N BLUE SAGE AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93730-8846
Mailing Address - Country:US
Mailing Address - Phone:559-538-0862
Mailing Address - Fax:
Practice Address - Street 1:11312 N BLUE SAGE AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93730-8846
Practice Address - Country:US
Practice Address - Phone:559-538-0862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001004844208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205281702Medicaid
MO205281702Medicaid
025012629Medicare ID - Type Unspecified