Provider Demographics
NPI:1588841340
Name:RASOOL, SHUJA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHUJA
Middle Name:
Last Name:RASOOL
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 1:2205 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-2759
Mailing Address - Country:US
Mailing Address - Phone:479-968-4311
Mailing Address - Fax:479-968-4399
Practice Address - Street 1:2205 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2759
Practice Address - Country:US
Practice Address - Phone:479-968-4311
Practice Address - Fax:479-968-4399
Is Sole Proprietor?:No
Enumeration Date:2008-01-23
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-7474207RC0000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR193879001Medicaid
AR5AR01C963Medicare PIN