Basic Information
| Provider Information | |||||||||
| NPI: | 1568679884 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAHROOZ | ||||||||
| FirstName: | FARIBORZ | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9656 SPRUANCE CT | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462569622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122387783 | ||||||||
| FaxNumber: | 8122384506 | ||||||||
| Practice Location | |||||||||
| Address1: | 9656 SPRUANCE CT | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462569622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122387783 | ||||||||
| FaxNumber: | 8122384506 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 08/24/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 01036398A | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 200353840 | 05 | IN | MEDICAID | 300126770 | 01 | IN | RR MEDICARE | OTHER |