Provider Demographics
NPI:1841225810
Name:SHIHATA, ALFRED (MD)
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:
Last Name:SHIHATA
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 1:340 4TH AVE STE 11
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-3813
Mailing Address - Country:US
Mailing Address - Phone:619-422-6158
Mailing Address - Fax:619-422-2019
Practice Address - Street 1:340 4TH AVE STE 11
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-3813
Practice Address - Country:US
Practice Address - Phone:619-422-6158
Practice Address - Fax:619-422-2019
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37090207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA37090OtherLICENSE
CAWA37090NMedicare PIN
CAA37090OtherLICENSE