Provider Demographics
NPI:1174621346
Name:JALISI, FARRUKH MAHFUZ (MD)
Entity type:Individual
Prefix:DR
First Name:FARRUKH
Middle Name:MAHFUZ
Last Name:JALISI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7845 OAKWOOD RD STE 106
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-4256
Mailing Address - Country:US
Mailing Address - Phone:410-760-5100
Mailing Address - Fax:410-760-5932
Practice Address - Street 1:7845 OAKWOOD RD STE 106
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-4256
Practice Address - Country:US
Practice Address - Phone:410-760-5100
Practice Address - Fax:410-760-5932
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20266207R00000X, 207RC0000X, 207RI0011X
NY241683207RC0000X, 207RI0011X
MDD84429207RC0000X, 207RI0011X
VA0101247118207RC0000X, 207RI0011X
IN01065461207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810018590Medicaid
OH3091112Medicaid
P00858196OtherMEDICARE RAILROAD
P00858196OtherMEDICARE RAILROAD