Provider Demographics
NPI:1073610689
Name:MOSHREF, MIR ABDUL KARIM (MD)
Entity Type:Individual
Prefix:
First Name:MIR ABDUL KARIM
Middle Name:
Last Name:MOSHREF
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 1:2110 LOWER HUNTINGTON RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46819-1235
Mailing Address - Country:US
Mailing Address - Phone:260-478-9960
Mailing Address - Fax:260-478-9670
Practice Address - Street 1:2110 LOWER HUNTINGTON RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46819-1235
Practice Address - Country:US
Practice Address - Phone:260-478-9960
Practice Address - Fax:260-478-9670
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-19
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042546207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100332850Medicaid
IN000000176706OtherANTHEM
IN100332850Medicaid
IN152010Medicare PIN
IN090430OMedicare PIN