Provider Demographics
NPI:1730262692
Name:NIAMATALI, HABIBOOLA (MD)
Entity type:Individual
Prefix:DR
First Name:HABIBOOLA
Middle Name:
Last Name:NIAMATALI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:HABIBOOLA
Other - Middle Name:
Other - Last Name:NIAMATALI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:10003 HICKORY XING
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-4615
Mailing Address - Country:US
Mailing Address - Phone:972-840-8599
Mailing Address - Fax:972-926-9970
Practice Address - Street 1:2121 NORTHWEST HWY
Practice Address - Street 2:SUITE#103
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75041-4858
Practice Address - Country:US
Practice Address - Phone:972-840-8599
Practice Address - Fax:972-926-9970
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1133207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112103003OtherMEDICAID THSTEP
TX112103002Medicaid
TX112103002Medicaid
TX00RF41Medicare PIN