Basic Information
Provider Information | |||||||||
NPI: | 1174697502 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ABDESSALAM | ||||||||
FirstName: | SHAHAB | ||||||||
MiddleName: | F | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 315 N SAN SABA STE 1135 | ||||||||
Address2: |   | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782073255 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2107044520 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 333 N SANTA ROSA | ||||||||
Address2: |   | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782073108 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2107044100 | ||||||||
FaxNumber: | 2107044037 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/18/2006 | ||||||||
LastUpdateDate: | 10/25/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/25/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | T7790 | TX | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 2086S0102X | 23626 | NE | N |   | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0120X | 23626 | NE | N |   | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery | 2086X0206X | 23626 | NE | N |   | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 2086S0120X | T7790 | TX | Y |   | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery |
ID Information
ID | Type | State | Issuer | Description | 250578 | 01 |   | MIDLANDS CHOICE | OTHER | 30422 | 01 | NE | BCBS | OTHER | 0721167 | 05 | IA |   | MEDICAID | 17-01116 | 01 |   | UHC | OTHER |