Provider Demographics
NPI:1891751079
Name:BOUSTANI, MALAZ A (MD)
Entity Type:Individual
Prefix:MR
First Name:MALAZ
Middle Name:A
Last Name:BOUSTANI
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:720 ESKENAZI AVE FL 6
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5189
Practice Address - Country:US
Practice Address - Phone:317-880-6600
Practice Address - Fax:317-880-0333
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01055882A207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000230417OtherANTHEM
IN200389990Medicaid
INH04088Medicare UPIN
IN200389990Medicaid
IN264430144Medicare PIN