Provider Demographics
NPI:1063130383
Name:DIABETES ASSOCIATES OF INDIANA P.C.
Entity type:Organization
Organization Name:DIABETES ASSOCIATES OF INDIANA P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOAZZAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HABIB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-590-2604
Mailing Address - Street 1:9526 PARK MERIDIAN DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1331
Mailing Address - Country:US
Mailing Address - Phone:317-652-9684
Mailing Address - Fax:
Practice Address - Street 1:9526 PARK MERIDIAN DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1331
Practice Address - Country:US
Practice Address - Phone:317-652-9684
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100358590Medicaid