MEDICARE: TARIK AL-KALLA M.D.

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	208600000X	Surgery Physician	1174887624	MI
2	208600000X	Surgery Physician	2018025701	MO
3	208600000X	Surgery Physician	S1034	TX

General Provider Information

NPI Number	:	1760726418
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARIK AL-KALLA M.D.

Provider Business Mailing Address
First Line	:	12606 GREENVILLE AVE STE 205
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75243-1927
Country	:	US
Telephone Number	:	214-971-8802
Fax Number	:	949-703-7227

Provider Business Practice Location Address
First Line	:	12606 GREENVILLE AVE STE 205
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75243-1927
Country	:	US
Telephone Number	:	214-971-8802
Fax Number	:	949-703-7227

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

Provider Enumeration Date	:	11/19/2012
Last Update Date	:	09/11/2024

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