Provider Demographics
NPI:1861655441
Name:JIDARIAN, ANOUSH (MD)
Entity type:Individual
Prefix:
First Name:ANOUSH
Middle Name:
Last Name:JIDARIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 RONALD REAGAN PKWY
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-7085
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1111 RONALD REAGAN PKWY
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-7085
Practice Address - Country:US
Practice Address - Phone:317-962-3400
Practice Address - Fax:317-963-5446
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01075161A208600000X, 208G00000X, 207RH0002X
GA65129208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1100207252OtherANTHEM PTAN
INP01549401OtherMEDICARE RAILROAD PTAN
GA003000013A,BMedicaid
IN201284900Medicaid
IN266180594Medicare PIN