Provider Demographics
NPI:1356573976
Name:BOUBES, KHALED (MD)
Entity type:Individual
Prefix:
First Name:KHALED
Middle Name:
Last Name:BOUBES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KHALED
Other - Middle Name:
Other - Last Name:BOOBES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-293-4837
Mailing Address - Fax:
Practice Address - Street 1:1800 ZOLLINGER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-2849
Practice Address - Country:US
Practice Address - Phone:614-293-4837
Practice Address - Fax:614-293-3125
Is Sole Proprietor?:No
Enumeration Date:2009-08-15
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-135916207RN0300X, 208M00000X
OH35.132671207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0254756Medicaid