Provider Demographics
NPI:1104141712
Name:BAKDASH, TARIF (MD)
Entity type:Individual
Prefix:
First Name:TARIF
Middle Name:
Last Name:BAKDASH
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 1:2195 HARRODSBURG RD FL 2
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2195 HARRODSBURG RD FL 2
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3516
Practice Address - Country:US
Practice Address - Phone:859-562-1868
Practice Address - Fax:859-257-0421
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012014535208000000X
MI4301055614208000000X, 2084N0402X
MT12298208000000X
WI630342084N0400X, 2084N0402X, 2084N0600X
MS245392084N0402X
KY585492084N0600X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431560263OtherTRICARE
MOP01110482OtherRR MCR
MT12298OtherLICENSE
AR192753001Medicaid
OK200435170AMedicaid
MS05127841Medicaid
MO1104141712Medicaid
MS524189YJ5DMedicare PIN
MT12298OtherLICENSE