Provider Demographics
NPI:1003077488
Name:MOAZZAM HABIB MD PC
Entity Type:Organization
Organization Name:MOAZZAM HABIB MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAMEER
Authorized Official - Middle Name:
Authorized Official - Last Name:HABIB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-571-0030
Mailing Address - Street 1:PO BOX 40686
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-0686
Mailing Address - Country:US
Mailing Address - Phone:317-571-0030
Mailing Address - Fax:317-571-0031
Practice Address - Street 1:9240 N MERIDIAN ST
Practice Address - Street 2:SUITE 240
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1880
Practice Address - Country:US
Practice Address - Phone:317-571-0030
Practice Address - Fax:317-571-0031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-19
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040236A207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100358590BMedicaid
IN000000200129OtherANTHEM
IN100358590BMedicaid
IN142280Medicare PIN