Provider Demographics
NPI:1073606356
Name:HADDAD, NASRALLAH (MD)
Entity Type:Individual
Prefix:
First Name:NASRALLAH
Middle Name:
Last Name:HADDAD
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 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 N RITTER AVE
Practice Address - Street 2:SUITE 330
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-3052
Practice Address - Country:US
Practice Address - Phone:317-355-1000
Practice Address - Fax:317-355-5440
Is Sole Proprietor?:No
Enumeration Date:2006-10-01
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031715A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1001764210Medicaid
IN000000764838OtherANTHEM
INP01227340OtherRR MEDICARE PTAN
IN000000497913OtherANTHEM BCBS ID
INM400074077Medicare PIN
IN249710AMedicare PIN
IN1001764210Medicaid