Provider Demographics
NPI:1285635334
Name:SALAM, GOHAR A (MD, FACS)
Entity Type:Individual
Prefix:DR
First Name:GOHAR
Middle Name:A
Last Name:SALAM
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11188 DIEBOLD RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-9662
Mailing Address - Country:US
Mailing Address - Phone:260-483-9500
Mailing Address - Fax:260-483-9511
Practice Address - Street 1:11188 DIEBOLD RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-9662
Practice Address - Country:US
Practice Address - Phone:260-483-9500
Practice Address - Fax:260-483-9511
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058885A207W00000X
IN130127411261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN7800696OtherAETNA
IN000000364631OtherANTHEM
IN17842OtherPHP
IN200484720AMedicaid
IN000000364631OtherANTHEM
INF95342Medicare UPIN
IN229700AMedicare PIN