Provider Demographics
NPI:1013967835
Name:DALATI, FAKHRI (MD)
Entity Type:Individual
Prefix:
First Name:FAKHRI
Middle Name:
Last Name:DALATI
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 1:320 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240-1965
Mailing Address - Country:US
Mailing Address - Phone:270-887-0100
Mailing Address - Fax:
Practice Address - Street 1:2520 5TH ST N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2008
Practice Address - Country:US
Practice Address - Phone:662-244-2042
Practice Address - Fax:662-244-2041
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19516207R00000X
TN38826208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3335918Medicaid
TN4129687OtherBCBS
TN3335918Medicaid
TN3335918Medicare ID - Type UnspecifiedMEDICARE#