Healthcare Provider Details

I. General information

NPI: 1649727827
Provider Name (Legal Business Name): ABDUSSALAM SHREDI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2016
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 4TH ST MS 9410
LUBBOCK TX
79430-0002
US

IV. Provider business mailing address

3601 4TH ST MS 9410
LUBBOCK TX
79430-0002
US

V. Phone/Fax

Practice location:
  • Phone: 806-743-3150
  • Fax: 806-743-2893
Mailing address:
  • Phone: 806-743-3150
  • Fax: 806-743-2893

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 State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number53066
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: