Healthcare Provider Details

I. General information

NPI: 1396249561
Provider Name (Legal Business Name): JASSER KHAIRALLAH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2018
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6002 E 38TH ST
INDIANAPOLIS IN
46226-5614
US

IV. Provider business mailing address

PO BOX 637764
CINCINNATI OH
45263-7764
US

V. Phone/Fax

Practice location:
  • Phone: 317-880-6002
  • Fax:
Mailing address:
  • Phone: 317-880-3939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number02006880A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: