Provider Demographics
NPI:1154416659
Name:BAKDALIEH, YAHYA (MD)
Entity type:Individual
Prefix:
First Name:YAHYA
Middle Name:
Last Name:BAKDALIEH
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 1:6347 SITKA SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-9031
Mailing Address - Country:US
Mailing Address - Phone:269-779-8985
Mailing Address - Fax:620-231-0081
Practice Address - Street 1:3025 GULL RD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1281
Practice Address - Country:US
Practice Address - Phone:269-552-2225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.090651207LP2900X, 208100000X
MI4301075956208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200265770AMedicaid
KS103811Medicare ID - Type Unspecified
KS200265770AMedicaid
I16610Medicare UPIN