Provider Demographics
NPI:1073636254
Name:LOGHMANI, TAYYEBEH (RD)
Entity Type:Individual
Prefix:
First Name:TAYYEBEH
Middle Name:
Last Name:LOGHMANI
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1111 N. RONALD REAGAN PKWY
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-7085
Practice Address - Country:US
Practice Address - Phone:317-217-3384
Practice Address - Fax:317-217-3386
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
IN37000716A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN264430189Medicare PIN