Provider Demographics
NPI:1376699199
Name:JAFFAR, REEMA (MD)
Entity Type:Individual
Prefix:
First Name:REEMA
Middle Name:
Last Name:JAFFAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:REEMA
Other - Middle Name:
Other - Last Name:VASENWALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:14275 MIDWAY RD
Mailing Address - Street 2:STE 400
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3676
Mailing Address - Country:US
Mailing Address - Phone:317-275-8072
Mailing Address - Fax:317-275-8124
Practice Address - Street 1:2560 N. SHADELAND AVENUE
Practice Address - Street 2:SUITE A
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-1706
Practice Address - Country:US
Practice Address - Phone:317-275-8072
Practice Address - Fax:317-275-8124
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036125439207ZP0213X
IN01071489A207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0213XAllopathic & Osteopathic PhysiciansPathologyPediatric Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201078570Medicaid
IN000000774700OtherANTHEM
IN352037910020OtherTRICARE
IN201078570Medicaid