MEDICARE: TAREK DABBOUSSI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program		IN
2	207QS1201X	Sleep Medicine (Family Medicine) Physician	02007283A	IN
3	207QS1201X	Sleep Medicine (Family Medicine) Physician	11020752A	IN

General Provider Information

NPI Number	:	1407419658
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAREK DABBOUSSI

Provider Business Mailing Address
First Line	:	6626 E 75TH ST STE 500
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46250-2890
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7250 CLEARVISTA DR STE 380
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46256-5608
Country	:	US
Telephone Number	:	317-621-3700
Fax Number	:	317-621-3701

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2019
Last Update Date	:	10/04/2023

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Directions to “ TAREK DABBOUSSI ” Practice Location

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