Provider Demographics
NPI:1760726418
Name:AL-KALLA, TARIK (MD)
Entity type:Individual
Prefix:
First Name:TARIK
Middle Name:
Last Name:AL-KALLA
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 1:12606 GREENVILLE AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-1927
Mailing Address - Country:US
Mailing Address - Phone:214-971-8802
Mailing Address - Fax:949-703-7227
Practice Address - Street 1:12606 GREENVILLE AVE STE 205
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-1927
Practice Address - Country:US
Practice Address - Phone:214-971-8802
Practice Address - Fax:949-703-7227
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-19
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1174887624208600000X
MO2018025701208600000X
TXS1034208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty