Provider Demographics
NPI:1548273394
Name:AL-KHATIB, AHMAD (MD)
Entity type:Individual
Prefix:
First Name:AHMAD
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 1:811 SE 28TH ST STE 5
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-4294
Mailing Address - Country:US
Mailing Address - Phone:479-254-9761
Mailing Address - Fax:479-254-9732
Practice Address - Street 1:811 SE 28TH ST STE 5
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-4294
Practice Address - Country:US
Practice Address - Phone:479-254-9761
Practice Address - Fax:479-254-9762
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35078468A2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2227861Medicaid
OH000000198168OtherANTHEM
OH000000198168OtherANTHEM
OH2227861Medicaid