Provider Demographics
NPI:1386683068
Name:SHAIKH, KHURRUM A (MD)
Entity Type:Individual
Prefix:
First Name:KHURRUM
Middle Name:A
Last Name:SHAIKH
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 1:6435 W JEFFERSON BLVD
Mailing Address - Street 2:PMB 109
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6203
Mailing Address - Country:US
Mailing Address - Phone:260-344-4035
Mailing Address - Fax:260-969-9272
Practice Address - Street 1:2520 E DUPONT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1675
Practice Address - Country:US
Practice Address - Phone:260-344-4035
Practice Address - Fax:260-969-9272
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061057207R00000X
OH35079807207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0064359Medicaid
IN200826790Medicaid
IN20549OtherPHP
IN000000547249OtherANTHEM
IN079774180OtherCIGNA
IN200826790Medicaid
ININ1945001Medicare PIN
IN20549OtherPHP
IN000000547249OtherANTHEM
OHP01138066Medicare PIN
OHH43228Medicare UPIN