Provider Demographics
NPI:1700225919
Name:KOLEILAT, SHADI MAHER (MD)
Entity Type:Individual
Prefix:
First Name:SHADI
Middle Name:MAHER
Last Name:KOLEILAT
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 1:2450 E RIVER RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-6526
Mailing Address - Country:US
Mailing Address - Phone:520-795-7750
Mailing Address - Fax:
Practice Address - Street 1:2450 E RIVER RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-6526
Practice Address - Country:US
Practice Address - Phone:520-795-7750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-20
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR741222084N0400X
AZ544822084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ389563Medicaid