Healthcare Provider Details

I. General information

NPI: 1417481946
Provider Name (Legal Business Name): BAHAEDDIN A. EL KHATIB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2017
Last Update Date: 04/05/2024
Certification Date: 04/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4676 DOUGLAS CIR NW
CANTON OH
44718-3619
US

IV. Provider business mailing address

4676 DOUGLAS CIR NW
CANTON OH
44718-3619
US

V. Phone/Fax

Practice location:
  • Phone: 330-494-1116
  • Fax:
Mailing address:
  • Phone: 330-494-1116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number35141623
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberMD479866
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number35.141623
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: