Provider Demographics
NPI:1700983863
Name:GADALLAH, SHIREEN F (MD)
Entity Type:Individual
Prefix:
First Name:SHIREEN
Middle Name:F
Last Name:GADALLAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 SILVER PALM AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3177
Mailing Address - Country:US
Mailing Address - Phone:321-725-4150
Mailing Address - Fax:321-733-1335
Practice Address - Street 1:25 SILVER PALM AVE
Practice Address - Street 2:SUITE B
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3177
Practice Address - Country:US
Practice Address - Phone:321-725-4150
Practice Address - Fax:321-733-1335
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME79573207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL256496300Medicaid
FL256496300Medicaid
FLF68489Medicare UPIN