Provider Demographics
NPI:1932442613
Name:ABDUSSALAM, ABDULLAH
Entity Type:Individual
Prefix:
First Name:ABDULLAH
Middle Name:
Last Name:ABDUSSALAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6278
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76115-0278
Mailing Address - Country:US
Mailing Address - Phone:817-568-5467
Mailing Address - Fax:817-568-5474
Practice Address - Street 1:2302 LONE STAR RD STE 200
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-8751
Practice Address - Country:US
Practice Address - Phone:682-341-7210
Practice Address - Fax:682-341-7212
Is Sole Proprietor?:No
Enumeration Date:2013-04-01
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS1745207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1932442613Medicaid