Healthcare Provider Details

I. General information

NPI: 1548474778
Provider Name (Legal Business Name): BABAK ETTEKAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 QUAKER LN # C2-4
WARWICK RI
02886-0159
US

IV. Provider business mailing address

PO BOX 746088
ATLANTA GA
30374-6088
US

V. Phone/Fax

Practice location:
  • Phone: 401-233-5051
  • Fax: 401-372-3445
Mailing address:
  • Phone: 312-733-9730
  • Fax: 773-866-8014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA91050
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD16998
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: