MEDICARE: OMAR IHSAN SHISHAKLY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	DT81652	TX

General Provider Information

NPI Number	:	1134632615
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OMAR IHSAN SHISHAKLY

Provider Business Mailing Address
First Line	:	10902 KATY FWY APT 1904
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77043-4915
Country	:	US
Telephone Number	:	832-858-0955
Fax Number	:

Provider Business Practice Location Address
First Line	:	10902 KATY FWY APT 1904
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77043-4915
Country	:	US
Telephone Number	:	832-858-0955
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2017
Last Update Date	:	11/07/2017

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Directions to “ OMAR IHSAN SHISHAKLY ” Practice Location

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