Provider Demographics
NPI:1083791719
Name:BAHRAMI, MOHAMMAD S (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:S
Last Name:BAHRAMI
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 1:3631 N MORRISON RD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-5547
Mailing Address - Country:US
Mailing Address - Phone:765-281-3443
Mailing Address - Fax:765-286-4124
Practice Address - Street 1:3631 N MORRISON RD
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-5547
Practice Address - Country:US
Practice Address - Phone:765-281-3443
Practice Address - Fax:765-286-4124
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035957207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100335920Medicaid
IN228050AMedicare PIN
IN100335920Medicaid
IN151560M9Medicare PIN
P00226901Medicare PIN