Healthcare Provider Details

I. General information

NPI: 1992726814
Provider Name (Legal Business Name): BACHAR AL KHATIB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 S PILGRIM BLVD
YORKTOWN IN
47396-9250
US

IV. Provider business mailing address

1200 W WHITE RIVER BLVD
MUNCIE IN
47303-4988
US

V. Phone/Fax

Practice location:
  • Phone: 765-759-4068
  • Fax: 765-759-4075
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01053337A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: