=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932220035
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAREK KTELEH MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2007
-----------------------------------------------------
Last Update Date | 02/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1107 S TILLOTSON AVE
-----------------------------------------------------
City | MUNCIE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47304-4517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-717-5399
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1107 S TILLOTSON AVE
-----------------------------------------------------
City | MUNCIE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47304-4517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-717-5399
-----------------------------------------------------
Fax | 855-792-0451
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 2006018669
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | 10801
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | 01068046A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------