Healthcare Provider Details

I. General information

NPI: 1265679187
Provider Name (Legal Business Name): ALA SHIYAB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2009
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2343 W LINCOLN RD
KOKOMO IN
46902
US

IV. Provider business mailing address

2343 W LINCOLN RD
KOKOMO IN
46902-8012
US

V. Phone/Fax

Practice location:
  • Phone: 765-455-4090
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number01066314A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: