Provider Demographics
NPI:1811278088
Name:SHAKHATREH, MOHAMMED IBRAHIM (MD)
Entity type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:IBRAHIM
Last Name:SHAKHATREH
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 1:475 SEAVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-3436
Mailing Address - Country:US
Mailing Address - Phone:718-226-9000
Mailing Address - Fax:
Practice Address - Street 1:2000 GRANT AVE STE 103
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-4378
Practice Address - Country:US
Practice Address - Phone:215-992-6002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-01
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.207078207R00000X
NY314288207RG0100X
TXR1291208M00000X
PAMD462390207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX404357201Medicaid
TXH08LV56001OtherBCBS-TEXAS