Basic Information
| Provider Information | |||||||||
| NPI: | 1659647717 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NISAR | ||||||||
| FirstName: | SHAHBAZ | ||||||||
| MiddleName: | SHAHID | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8558 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464107032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193927084 | ||||||||
| FaxNumber: | 2197036854 | ||||||||
| Practice Location | |||||||||
| Address1: | 4940 W CLARK RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481970860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349711188 | ||||||||
| FaxNumber: | 7349713658 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2012 | ||||||||
| LastUpdateDate: | 12/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01084868A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 4301100567 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.