Provider Demographics
NPI:1790895571
Name:RESHEIDAT, SHADI M (MD)
Entity Type:Individual
Prefix:
First Name:SHADI
Middle Name:M
Last Name:RESHEIDAT
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:PO BOX 4699
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-4699
Mailing Address - Country:US
Mailing Address - Phone:765-449-2732
Mailing Address - Fax:765-449-1196
Practice Address - Street 1:3554 PROMENADE PKWY
Practice Address - Street 2:SUITE F
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47909-8418
Practice Address - Country:US
Practice Address - Phone:765-471-9146
Practice Address - Fax:765-477-0277
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058532A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000382394OtherANTHEM PROVIDER NUMBER
IN200522260Medicaid
INI33582Medicare UPIN
INP00317653Medicare PIN
IN200522260Medicaid