Healthcare Provider Details

I. General information

NPI: 1861632168
Provider Name (Legal Business Name): ALMOUTAZ BELLAH SHAKALLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2009
Last Update Date: 11/12/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

399 E HIGHLAND AVE STE 227
SAN BERNARDINO CA
92404-3851
US

IV. Provider business mailing address

5450 JEFFERSON AVE STE 2
CHINO CA
91710-3522
US

V. Phone/Fax

Practice location:
  • Phone: 612-616-3963
  • Fax:
Mailing address:
  • Phone: 909-882-1210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number63294
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD-39303
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number39303
License Number StateIA
# 5
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberA154138
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: