Provider Demographics
NPI:1992726814
Name:AL KHATIB, BACHAR (MD)
Entity type:Individual
Prefix:
First Name:BACHAR
Middle Name:
Last Name:AL KHATIB
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 1:1200 W WHITE RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-4988
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1420 S PILGRIM BLVD
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:IN
Practice Address - Zip Code:47396-9250
Practice Address - Country:US
Practice Address - Phone:765-759-4068
Practice Address - Fax:765-759-4075
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-23
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01053337A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200295820AMedicaid
INH29941Medicare UPIN
IN168610Medicare PIN
INM22404039Medicare PIN