Provider Demographics
NPI:1639270721
Name:HABIB, MOAZZAM W (MD)
Entity type:Individual
Prefix:
First Name:MOAZZAM
Middle Name:W
Last Name:HABIB
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:PO BOX 40686
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-0686
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9240 N MERIDIAN ST
Practice Address - Street 2:SUITE 240
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1880
Practice Address - Country:US
Practice Address - Phone:317-571-0030
Practice Address - Fax:317-571-0031
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040236A207RE0101X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000200129OtherANTHEM
IN100358590Medicaid
IN352135010OtherTAX ID #
INE13378Medicare UPIN
IN142280Medicare PIN