Healthcare Provider Details

I. General information

NPI: 1295863041
Provider Name (Legal Business Name): DAFALLA O ELOBAID
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: SEIFELDIN E MOHAMED D E

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 02/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2346 S LYNHURST DR
INDIANAPOLIS IN
46241-8621
US

IV. Provider business mailing address

PO BOX 22295
INDIANAPOLIS IN
46222-0295
US

V. Phone/Fax

Practice location:
  • Phone: 317-247-7993
  • Fax:
Mailing address:
  • Phone: 317-319-8521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: