Provider Demographics
NPI:1972584043
Name:SEDAGHAT, VAHID-DAVID (MD)
Entity Type:Individual
Prefix:
First Name:VAHID-DAVID
Middle Name:
Last Name:SEDAGHAT
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 1:330 N WABASH AVE STE G-20
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2605
Mailing Address - Country:US
Mailing Address - Phone:765-660-7600
Mailing Address - Fax:765-651-7313
Practice Address - Street 1:3512 STELLHORN RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-4631
Practice Address - Country:US
Practice Address - Phone:260-483-9081
Practice Address - Fax:260-483-9196
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056095A208M00000X, 207R00000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200398430Medicaid
IN000000659555OtherANTHEM
INM400016968Medicare PIN
IN217670CMedicare PIN
INM400016968Medicare PIN
IN266180851Medicare PIN
ININ1663052Medicare PIN