Basic Information
Provider Information | |||||||||
NPI: | 1922205079 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ZAKY SALAMA | ||||||||
FirstName: | WADID | ||||||||
MiddleName: | YOUSSEF | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2145 COUNTRY CLUB RD | ||||||||
Address2: |   | ||||||||
City: | JACKSONVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 285462400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9109395759 | ||||||||
FaxNumber: | 9109394951 | ||||||||
Practice Location | |||||||||
Address1: | 2145 COUNTRY CLUB RD | ||||||||
Address2: |   | ||||||||
City: | JACKSONVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 285462400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9109395759 | ||||||||
FaxNumber: | 9109394951 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/02/2007 | ||||||||
LastUpdateDate: | 07/06/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 0101252883 | VA | N |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207LP2900X | 2016-00023 | NC | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207R00000X | 232877 | MA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1922205079 | 05 | VA |   | MEDICAID |