Provider Demographics
NPI:1619471810
Name:GABALLA, SALEM T (MBBCH)
Entity Type:Individual
Prefix:
First Name:SALEM
Middle Name:T
Last Name:GABALLA
Suffix:
Gender:M
Credentials:MBBCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 PENNSYLVANIA AVE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20037-3201
Mailing Address - Country:US
Mailing Address - Phone:202-741-3000
Mailing Address - Fax:
Practice Address - Street 1:2535 MAPLECREST RD STE 10
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-2799
Practice Address - Country:US
Practice Address - Phone:563-421-4620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-21
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD51337207RE0101X
390200000X
DCMD049256390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty