Provider Demographics
NPI:1770456253
Name:ZAKHOUR, SHADI
Entity type:Individual
Prefix:
First Name:SHADI
Middle Name:
Last Name:ZAKHOUR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1364 S COBBLE CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-7138
Mailing Address - Country:US
Mailing Address - Phone:812-505-9442
Mailing Address - Fax:
Practice Address - Street 1:451 S PARK RIDGE RD # 101
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-8589
Practice Address - Country:US
Practice Address - Phone:812-747-9384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-29
Last Update Date:2025-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities