Provider Demographics
NPI:1942268057
Name:ETEMAD, BABAK (MD)
Entity Type:Individual
Prefix:DR
First Name:BABAK
Middle Name:
Last Name:ETEMAD
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 1:100 E LANCASTER AVE STE 560
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-3450
Mailing Address - Country:US
Mailing Address - Phone:484-476-8390
Mailing Address - Fax:484-476-7841
Practice Address - Street 1:100 E LANCASTER AVE STE 560
Practice Address - Street 2:
Practice Address - City:WYNNEWOOD
Practice Address - State:PA
Practice Address - Zip Code:19096
Practice Address - Country:US
Practice Address - Phone:484-476-8390
Practice Address - Fax:484-476-7841
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD049259L207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1185345Medicaid
LA1185345Medicaid
LA4E808Medicare ID - Type Unspecified