Provider Demographics
NPI:1245491083
Name:ELTARABOULSI, WALID RAOUF (MD)
Entity type:Individual
Prefix:DR
First Name:WALID
Middle Name:RAOUF
Last Name:ELTARABOULSI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10320 FELD FARM LN STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8484
Practice Address - Country:US
Practice Address - Phone:980-488-9870
Practice Address - Fax:980-488-9875
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC86883207R00000X, 207RC0200X, 207RP1001X
NC2011-01032207RC0200X, 207RP1001X
NC207RP1001X207RP1001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1245491083Medicaid
SCNC2170Medicaid
NC2011-01032OtherNC LICENSE
SCNC2170Medicaid