Provider Demographics
NPI:1376717744
Name:SUBHAN, ABDUL (MD)
Entity Type:Individual
Prefix:
First Name:ABDUL
Middle Name:
Last Name:SUBHAN
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 1:240 N TILLOTSON AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-3988
Mailing Address - Country:US
Mailing Address - Phone:765-288-1928
Mailing Address - Fax:765-741-0335
Practice Address - Street 1:2506 WILLOWBROOK PKWY STE 102A
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-1542
Practice Address - Country:US
Practice Address - Phone:317-803-2270
Practice Address - Fax:317-217-1769
Is Sole Proprietor?:No
Enumeration Date:2008-04-16
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49780-20207Q00000X
OH57.0124382084P0800X
IN01065489A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200958640Medicaid
INM400056017Medicare PIN
INM400056013Medicare PIN