Provider Demographics
NPI:1104037886
Name:SOMANI, ALLY-KHAN B (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:ALLY-KHAN
Middle Name:B
Last Name:SOMANI
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16105 S LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-5503
Practice Address - Country:US
Practice Address - Phone:708-636-3767
Practice Address - Fax:708-873-5849
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.091501207N00000X
IN01066254A207N00000X, 207ND0101X, 207NS0135X
IL036149454207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200945370Medicaid
INP00741989Medicare PIN
IN132590SSMedicare PIN