Provider Demographics
NPI:1649227091
Name:ATALLAH, MARWAN
Entity Type:Individual
Prefix:
First Name:MARWAN
Middle Name:
Last Name:ATALLAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 117
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11228-0117
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:142 JORALEMON ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-4709
Practice Address - Country:US
Practice Address - Phone:718-643-9371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY128270208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00247232Medicaid
NY318661Medicare PIN
NY00247232Medicaid