Provider Demographics
NPI:1114922044
Name:DABASH, KHALED A (MD)
Entity Type:Individual
Prefix:
First Name:KHALED
Middle Name:A
Last Name:DABASH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 E GRANT ST
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-3368
Mailing Address - Country:US
Mailing Address - Phone:309-836-5437
Mailing Address - Fax:309-836-5417
Practice Address - Street 1:515 E GRANT ST
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3368
Practice Address - Country:US
Practice Address - Phone:309-836-5437
Practice Address - Fax:309-836-5417
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036089170208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5522926OtherBLUE CROSS/BLUE SHIELD
IL010060OtherHEALTH ALLIANCE
IL036089170Medicaid
F89066Medicare UPIN
IL036089170Medicaid