Provider Demographics
NPI:1376650317
Name:KHATTAB, YASSIN (MD)
Entity Type:Individual
Prefix:
First Name:YASSIN
Middle Name:
Last Name:KHATTAB
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 1:822 S MAYO TRL
Mailing Address - Street 2:
Mailing Address - City:PAINTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41240-1384
Mailing Address - Country:US
Mailing Address - Phone:606-789-5541
Mailing Address - Fax:606-789-9445
Practice Address - Street 1:822 S MAYO TRL
Practice Address - Street 2:
Practice Address - City:PAINTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41240-1384
Practice Address - Country:US
Practice Address - Phone:606-789-5541
Practice Address - Fax:606-789-9445
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31556207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000203757OtherBLUE CROSS/BLUE SHIELD
KY31001019Medicaid
KY64315567Medicaid
KY65935025Medicaid
KY01287001Medicare PIN
KY65935025Medicaid