Provider Demographics
NPI:1922100320
Name:SHAHATTO, NAEL M (MD)
Entity Type:Individual
Prefix:
First Name:NAEL
Middle Name:M
Last Name:SHAHATTO
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 1:22421 BARTON RD # 296
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5008
Mailing Address - Country:US
Mailing Address - Phone:909-883-9953
Mailing Address - Fax:909-883-2840
Practice Address - Street 1:399 E HIGHLAND AVE
Practice Address - Street 2:STE 309
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404
Practice Address - Country:US
Practice Address - Phone:909-883-9953
Practice Address - Fax:909-883-2840
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52423207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A524230Medicaid
CA00A524230Medicaid
F82535Medicare UPIN