Healthcare Provider Details

I. General information

NPI: 1356044432
Provider Name (Legal Business Name): ALI KHAMBATI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11109 PARKVIEW PLAZA DR
FORT WAYNE IN
46845-1701
US

IV. Provider business mailing address

7007 POWERS BLVD
PARMA OH
44129-5437
US

V. Phone/Fax

Practice location:
  • Phone: 260-672-6620
  • Fax: 260-672-6639
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number02008839A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: