Provider Demographics
NPI:1396737524
Name:KHATIB, SIRAJABID (MD)
Entity type:Individual
Prefix:
First Name:SIRAJABID
Middle Name:
Last Name: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 1:330 N WABASH
Mailing Address - Street 2:SUITE G20
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2600
Mailing Address - Country:US
Mailing Address - Phone:765-660-7600
Mailing Address - Fax:765-651-7313
Practice Address - Street 1:441 N WABASH AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2612
Practice Address - Country:US
Practice Address - Phone:765-662-4236
Practice Address - Fax:765-662-4903
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01050026A208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200375870Medicaid
IN000001150856OtherANTHEM