Provider Demographics
NPI:1548474778
Name:ETTEKAL, BABAK (MD)
Entity type:Individual
Prefix:DR
First Name:BABAK
Middle Name:
Last Name:ETTEKAL
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:PO BOX 746088
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6088
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:773-866-8014
Practice Address - Street 1:300 QUAKER LN # C2-4
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-0159
Practice Address - Country:US
Practice Address - Phone:401-233-5051
Practice Address - Fax:401-372-3445
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA91050207Q00000X
RIMD16998207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine