Provider Demographics
NPI:1124013578
Name:JAN, ABDALI S (MD)
Entity Type:Individual
Prefix:DR
First Name:ABDALI
Middle Name:S
Last Name:JAN
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:PO BOX 236
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:IN
Mailing Address - Zip Code:46761-0236
Mailing Address - Country:US
Mailing Address - Phone:260-463-2133
Mailing Address - Fax:260-463-3775
Practice Address - Street 1:610 N SAWYER RD
Practice Address - Street 2:
Practice Address - City:KENDALLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46755-2566
Practice Address - Country:US
Practice Address - Phone:260-347-5592
Practice Address - Fax:260-347-5155
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01051996A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301070135OtherMICHIGAN LICENSE
IN200301010Medicaid
INH35996Medicare UPIN
MI4301070135OtherMICHIGAN LICENSE
IN194020CMedicare ID - Type Unspecified