Provider Demographics
NPI:1891980462
Name:SHAREEF, FAIZUDDIN (DO)
Entity Type:Individual
Prefix:DR
First Name:FAIZUDDIN
Middle Name:
Last Name:SHAREEF
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 1:2640 HAMSTROM RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-3832
Mailing Address - Country:US
Mailing Address - Phone:219-762-4423
Mailing Address - Fax:
Practice Address - Street 1:2640 HAMSTROM RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-3832
Practice Address - Country:US
Practice Address - Phone:219-762-4423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02003711A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200990690Medicaid
P00603112Medicare PIN
INM400048831Medicare PIN