Healthcare Provider Details

I. General information

NPI: 1568143881
Provider Name (Legal Business Name): AHMED FARAGALLAH IBRAHIM FARAGALLAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2023
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 BOB BABBS DR
SPENCER IN
47460-6828
US

IV. Provider business mailing address

8003 CASTLEWAY DR
INDIANAPOLIS IN
46250-1946
US

V. Phone/Fax

Practice location:
  • Phone: 812-652-1700
  • Fax: 812-954-5023
Mailing address:
  • Phone: 317-576-1335
  • Fax: 317-343-6562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01099135A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: