Provider Demographics
NPI:1659534238
Name:GABALLA, SAMEH REFAT (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMEH
Middle Name:REFAT
Last Name:GABALLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 CHESTNUT ST STE 220
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4405
Mailing Address - Country:US
Mailing Address - Phone:215-955-6060
Mailing Address - Fax:215-923-8226
Practice Address - Street 1:925 CHESTNUT ST
Practice Address - Street 2:SUITE 320A
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4216
Practice Address - Country:US
Practice Address - Phone:215-955-8874
Practice Address - Fax:215-955-2340
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-03
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT192010207R00000X
PAMD444821207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103060847 0001Medicaid
NJ0481025Medicaid
PA103060847 0002Medicaid
PA103060847 0002Medicaid