Provider Demographics
NPI:1588059356
Name:AJAM, TAREK (MD)
Entity type:Individual
Prefix:
First Name:TAREK
Middle Name:
Last Name:AJAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8558 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7032
Mailing Address - Country:US
Mailing Address - Phone:219-392-7084
Mailing Address - Fax:219-703-6854
Practice Address - Street 1:1500 S LAKE PARK AVE STE 110
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-6638
Practice Address - Country:US
Practice Address - Phone:219-947-6017
Practice Address - Fax:219-947-6018
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6867620207R00000X
WI68676-20207RC0000X
IN01089618A207RC0001X
MO390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300073465Medicaid