Provider Demographics
NPI:1912953373
Name:ALAM, SHAMSUL (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAMSUL
Middle Name:
Last Name:ALAM
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 1:11149 COBBLESTONE
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-7379
Mailing Address - Country:US
Mailing Address - Phone:479-271-9393
Mailing Address - Fax:479-271-0141
Practice Address - Street 1:2618 SE J ST
Practice Address - Street 2:SUITE # 2 & 4
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3767
Practice Address - Country:US
Practice Address - Phone:479-271-9393
Practice Address - Fax:479-271-0141
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE4954207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200277530AMedicaid
AR168252001Medicaid
OK27959OtherOKLAHOMA STATE MEDICAL LICENSE
ARA68252001Medicaid
ARA68252001Medicaid
ARG82485Medicare UPIN