Provider Demographics
NPI:1295863041
Name:ELOBAID, DAFALLA O
Entity Type:Individual
Prefix:
First Name:DAFALLA
Middle Name:O
Last Name:ELOBAID
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:SEIFELDIN
Other - Middle Name:E
Other - Last Name:MOHAMED
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:D E
Mailing Address - Street 1:PO BOX 22295
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46222-0295
Mailing Address - Country:US
Mailing Address - Phone:317-319-8521
Mailing Address - Fax:
Practice Address - Street 1:2346 S LYNHURST DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241-8621
Practice Address - Country:US
Practice Address - Phone:317-247-7993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor