Provider Demographics
NPI:1861632168
Name:SHAKALLY, ALMOUTAZ BELLAH (MD)
Entity Type:Individual
Prefix:
First Name:ALMOUTAZ
Middle Name:BELLAH
Last Name:SHAKALLY
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 1:5450 JEFFERSON AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-3522
Mailing Address - Country:US
Mailing Address - Phone:909-882-1210
Mailing Address - Fax:
Practice Address - Street 1:399 E HIGHLAND AVE STE 227
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3851
Practice Address - Country:US
Practice Address - Phone:612-616-3963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-26
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN63294207R00000X
IAMD-39303207R00000X
IA39303207R00000X
390200000X
CAA154138207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program