Provider Demographics
NPI:1750661526
Name:KHAYAMBASHI, SHAGHAYEGH (MD)
Entity Type:Individual
Prefix:
First Name:SHAGHAYEGH
Middle Name:
Last Name:KHAYAMBASHI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 CLINICAL DR RM CL370
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5233
Mailing Address - Country:US
Mailing Address - Phone:317-274-7177
Mailing Address - Fax:317-274-7792
Practice Address - Street 1:541 CLINICAL DR RM CL370
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5233
Practice Address - Country:US
Practice Address - Phone:317-274-7177
Practice Address - Fax:317-274-7792
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-24
Last Update Date:2014-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR72516207R00000X
IN11017774A390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN11017774AOtherMEDICAL RESIDENCY PERMIT
AZR72516OtherTRAINING PERMIT