Healthcare Provider Details

I. General information

NPI: 1831156538
Provider Name (Legal Business Name): EYAS HATTAB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 04/24/2023
Certification Date: 04/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 S JACKSON ST # A1H01
LOUISVILLE KY
40202-1675
US

IV. Provider business mailing address

635 BARNHILL DR A128
INDIANAPOLIS IN
46202-5126
US

V. Phone/Fax

Practice location:
  • Phone: 502-852-8235
  • Fax:
Mailing address:
  • Phone: 317-274-4806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License Number49038
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License Number01055843A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number01055843A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number49038
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: