Provider Demographics
NPI:1790883692
Name:MOLLABASHY, DJAVAD (MD)
Entity Type:Individual
Prefix:
First Name:DJAVAD
Middle Name:
Last Name:MOLLABASHY
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 1:3903 S 7TH ST
Mailing Address - Street 2:SUITE 1F
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802
Mailing Address - Country:US
Mailing Address - Phone:812-232-2032
Mailing Address - Fax:812-232-8252
Practice Address - Street 1:3903 S 7TH ST
Practice Address - Street 2:SUITE 1F
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802
Practice Address - Country:US
Practice Address - Phone:812-232-2032
Practice Address - Fax:812-232-8252
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028243207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000000241048OtherANTHEM
IN132600HMedicare ID - Type Unspecified
B29717Medicare UPIN