Provider Demographics
NPI:1770614604
Name:SHAHROOZ DERMATOLOGY CENTER PC
Entity type:Organization
Organization Name:SHAHROOZ DERMATOLOGY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NAHID
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAHROOZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-859-9859
Mailing Address - Street 1:8051 S EMERSON AVE
Mailing Address - Street 2:STE 450
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-8600
Mailing Address - Country:US
Mailing Address - Phone:317-859-9859
Mailing Address - Fax:317-859-3265
Practice Address - Street 1:8051 S EMERSON AVE
Practice Address - Street 2:STE 450
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8600
Practice Address - Country:US
Practice Address - Phone:317-859-9859
Practice Address - Fax:317-859-3265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036322A207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000356359OtherANTHEM PIN
IN1649272097OtherPHYSICIAN NPI
IN000000356359OtherANTHEM PIN
INE06462Medicare UPIN