Provider Demographics
NPI:1508174376
Name:BRAIK, TAREQ (MD)
Entity Type:Individual
Prefix:
First Name:TAREQ
Middle Name:
Last Name:BRAIK
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 1:2022 KELLE DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-8708
Mailing Address - Country:US
Mailing Address - Phone:219-364-3616
Mailing Address - Fax:219-364-3610
Practice Address - Street 1:85 E US HIGHWAY 6 STE 200
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-8947
Practice Address - Country:US
Practice Address - Phone:219-983-6260
Practice Address - Fax:219-983-6060
Is Sole Proprietor?:No
Enumeration Date:2010-09-15
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2011-0742207RH0003X
IN01077904A207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1932187044OtherGROUP NPI
NM83221328Medicaid
NMP01121737OtherMEDICARE RAILROAD CARRIER
NMZ2565OtherGROUP MCD
NM800521089OtherGROUP MCR
NMZ2565OtherGROUP MCD
NM83221328Medicaid