Provider Demographics
NPI:1275844102
Name:MOSHREF, SHABNAM (DO)
Entity Type:Individual
Prefix:
First Name:SHABNAM
Middle Name:
Last Name:MOSHREF
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E. 75TH STREET
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:317-497-6333
Mailing Address - Fax:317-497-1919
Practice Address - Street 1:8920 SOUTHPOINTE DR
Practice Address - Street 2:SUITE B
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-7509
Practice Address - Country:US
Practice Address - Phone:317-497-1900
Practice Address - Fax:317-497-1919
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-25
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02004349A207R00000X
MI5101018943208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2010202340Medicaid
INP01347725OtherMEDICARE RR PTAN
IN2010202340Medicaid