Healthcare Provider Details

I. General information

NPI: 1689638033
Provider Name (Legal Business Name): TAREK KUDAIMI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 02/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 MACARTHUR BLVD SUITE 305
MUNSTER IN
46321-2915
US

IV. Provider business mailing address

801 MACARTHUR BLVD SUITE 305
MUNSTER IN
46321-2915
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-1310
  • Fax: 219-836-0617
Mailing address:
  • Phone: 219-836-1310
  • Fax: 219-836-0617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number01044239
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01044239
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: