Provider Demographics
NPI:1932220035
Name:KTELEH, TAREK (MD)
Entity Type:Individual
Prefix:
First Name:TAREK
Middle Name:
Last Name:KTELEH
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 1:3550 W FOX RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-5205
Mailing Address - Country:US
Mailing Address - Phone:765-281-2188
Mailing Address - Fax:765-281-2062
Practice Address - Street 1:3550 W FOX RIDGE LN
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-5205
Practice Address - Country:US
Practice Address - Phone:765-717-5399
Practice Address - Fax:765-216-6774
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006018669174400000X
ND10801207RR0500X
IN01068046A207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200980090Medicaid
IN200980090Medicaid