Provider Demographics
NPI:1487761607
Name:ARDALAN, ABDOLAZIZ M (MD)
Entity type:Individual
Prefix:MR
First Name:ABDOLAZIZ
Middle Name:M
Last Name:ARDALAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9737 DECATUR DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-9656
Mailing Address - Country:US
Mailing Address - Phone:317-578-1133
Mailing Address - Fax:317-537-2862
Practice Address - Street 1:9737 DECATUR DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-9656
Practice Address - Country:US
Practice Address - Phone:317-578-1133
Practice Address - Fax:317-843-2727
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0102672012086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100367790AMedicaid
IN000000079426OtherANTHEM BLUE SHIELD
IN100367790AMedicaid
INB20079Medicare UPIN