Provider Demographics
NPI:1598943045
Name:JALLAD, NISREEN A (MD, FACC)
Entity Type:Individual
Prefix:DR
First Name:NISREEN
Middle Name:A
Last Name:JALLAD
Suffix:
Gender:F
Credentials:MD, FACC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 WATSON BLVD
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-3606
Mailing Address - Country:US
Mailing Address - Phone:478-929-8030
Mailing Address - Fax:478-929-8095
Practice Address - Street 1:1707 WATSON BLVD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-3606
Practice Address - Country:US
Practice Address - Phone:478-929-8030
Practice Address - Fax:478-929-8095
Is Sole Proprietor?:No
Enumeration Date:2008-02-07
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA073857207RI0011X, 207RI0011X
GA072857207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003162364AMedicare UPIN