Provider Demographics
NPI:1154331254
Name:FIDAHUSSEIN, MUSTAFA HASSANALI (MD)
Entity Type:Individual
Prefix:
First Name:MUSTAFA
Middle Name:HASSANALI
Last Name:FIDAHUSSEIN
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 1:8910 PURDUE RD
Mailing Address - Street 2:STE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-3161
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 W 10TH ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2859
Practice Address - Country:US
Practice Address - Phone:317-630-7979
Practice Address - Fax:317-630-2668
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0064480207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200999920Medicaid
IN000000693425OtherANTHEM
IN200999920Medicaid