Healthcare Provider Details

I. General information

NPI: 1932220035
Provider Name (Legal Business Name): TAREK KTELEH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 02/10/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 S TILLOTSON AVE
MUNCIE IN
47304-4517
US

IV. Provider business mailing address

1107 S TILLOTSON AVE
MUNCIE IN
47304-4517
US

V. Phone/Fax

Practice location:
  • Phone: 765-717-5399
  • Fax:
Mailing address:
  • Phone: 765-717-5399
  • Fax: 855-792-0451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number2006018669
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number10801
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number01068046A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: