Provider Demographics
NPI:1851812572
Name:MEHDI, SHAUN SADRUDDIN (DO)
Entity Type:Individual
Prefix:DR
First Name:SHAUN
Middle Name:SADRUDDIN
Last Name:MEHDI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2022 KELLE DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-8708
Mailing Address - Country:US
Mailing Address - Phone:219-364-3616
Mailing Address - Fax:219-364-3610
Practice Address - Street 1:6200 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-3702
Practice Address - Country:US
Practice Address - Phone:219-762-1040
Practice Address - Fax:219-762-1041
Is Sole Proprietor?:No
Enumeration Date:2017-07-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125071534207R00000X
IN02005976A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine