Healthcare Provider Details

I. General information

NPI: 1437976784
Provider Name (Legal Business Name): GHASSAN ELSHATARAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2024
Last Update Date: 09/26/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 NE 24TH ST STE 107
MIAMI FL
33137-5040
US

IV. Provider business mailing address

10625 MAJOR AVE APT 2N
CHICAGO RIDGE IL
60415-2323
US

V. Phone/Fax

Practice location:
  • Phone: 224-733-9546
  • Fax:
Mailing address:
  • Phone: 224-733-9546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: