Basic Information
| Provider Information | |||||||||
| NPI: | 1710979091 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHALAN | ||||||||
| FirstName: | GREGG | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 W COLORADO BLVD STE 525 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752082312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149564525 | ||||||||
| FaxNumber: | 2149605681 | ||||||||
| Practice Location | |||||||||
| Address1: | 221 W COLORADO BLVD STE 525 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752082312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149564525 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 11/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | J8126 | TX | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084A2900X | J8126 | TX | Y |
ID Information
| ID | Type | State | Issuer | Description | 112880305 | 01 | TX | TPI | OTHER | PO88X2302 | 05 | TX | MEDICAID |