Provider Demographics
NPI:1568679884
Name:SHAHROOZ, FARIBORZ (MD)
Entity Type:Individual
Prefix:
First Name:FARIBORZ
Middle Name:
Last Name:SHAHROOZ
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 1:9656 SPRUANCE CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-9622
Mailing Address - Country:US
Mailing Address - Phone:812-238-7783
Mailing Address - Fax:812-238-4506
Practice Address - Street 1:9656 SPRUANCE CT
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-9622
Practice Address - Country:US
Practice Address - Phone:812-238-7783
Practice Address - Fax:812-238-4506
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036398A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200353840Medicaid
IN300126770OtherRR MEDICARE
IN941090T9Medicare PIN
IN300126770OtherRR MEDICARE
IN184380QMedicare PIN