Basic Information
| Provider Information | |||||||||
| NPI: | 1275844102 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOSHREF | ||||||||
| FirstName: | SHABNAM | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E. 75TH STREET | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174976333 | ||||||||
| FaxNumber: | 3174971919 | ||||||||
| Practice Location | |||||||||
| Address1: | 8920 SOUTHPOINTE DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462277509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174971900 | ||||||||
| FaxNumber: | 3174971919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2010 | ||||||||
| LastUpdateDate: | 09/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 02004349A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208D00000X | 5101018943 | MI | N | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 2010202340 | 05 | IN | MEDICAID | P01347725 | 01 | IN | MEDICARE RR PTAN | OTHER |