Healthcare Provider Details

I. General information

NPI: 1316129695
Provider Name (Legal Business Name): HUSAM BAKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: HUSAM ABDULBAKI M.D.

II. Dates (important events)

Enumeration Date: 11/29/2007
Last Update Date: 10/30/2024
Certification Date: 10/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 STATE ST
LA PORTE IN
46350-3112
US

IV. Provider business mailing address

50925 SAFARI DR
GRANGER IN
46530-6737
US

V. Phone/Fax

Practice location:
  • Phone: 219-326-1234
  • Fax:
Mailing address:
  • Phone: 312-451-4630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number01056375A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01056375A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: