Basic Information
Provider Information | |||||||||
NPI: | 1861996555 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHITIA | ||||||||
FirstName: | MOHAMED | ||||||||
MiddleName: | HUSAM | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 8310 | ||||||||
Address2: |   | ||||||||
City: | ROANOKE | ||||||||
State: | VA | ||||||||
PostalCode: | 240140310 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5403453556 | ||||||||
FaxNumber: | 5403422193 | ||||||||
Practice Location | |||||||||
Address1: | 1691 INNOVATION DR STE 2100 | ||||||||
Address2: |   | ||||||||
City: | BLACKSBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 240606618 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5402328405 | ||||||||
FaxNumber: | 5402328429 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/19/2018 | ||||||||
LastUpdateDate: | 04/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 34.015318 | OH | N |   | Allopathic & Osteopathic Physicians | General Practice |   | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 204D00000X | 0102207057 | VA | Y |   | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM |   |
No ID Information.