Healthcare Provider Details

I. General information

NPI: 1245753607
Provider Name (Legal Business Name): MANAR SHALAK M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2017
Last Update Date: 10/31/2022
Certification Date: 10/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL DRIVE
MORGANTOWN WV
26506
US

IV. Provider business mailing address

1 MEDICAL DRIVE
MORGANTOWN WV
26506
US

V. Phone/Fax

Practice location:
  • Phone: 304-293-5550
  • Fax: 304-293-2544
Mailing address:
  • Phone: 304-293-5550
  • Fax: 304-293-2544

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 Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number31050
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number31050
License Number StateWV
# 4
Primary TaxonomyN
Taxonomy Code2278P3800X
TaxonomyPalliative/Hospice Certified Respiratory Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: