Healthcare Provider Details

I. General information

NPI: 1922701143
Provider Name (Legal Business Name): NOUREDEAN KHRISAT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DEAN KHRISAT DO

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 06/27/2024
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 UNIVERSITY BLVD
INDIANAPOLIS IN
46202-5149
US

IV. Provider business mailing address

8629 MCVICKER AVE
BURBANK IL
60459-2511
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-0275
  • Fax: 317-274-0256
Mailing address:
  • Phone: 708-238-1227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: