MEDICARE: ABDUL SUBHAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	49780-20	WI
2	2084P0800X	Psychiatry Physician	57.012438	OH
3	2084P0800X	Psychiatry Physician	01065489A	IN

General Provider Information

NPI Number	:	1376717744
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ABDUL SUBHAN M.D.

Provider Business Mailing Address
First Line	:	240 N TILLOTSON AVE
Second Line	:
City	:	MUNCIE
State	:	IN
Zip	:	47304-3988
Country	:	US
Telephone Number	:	765-288-1928
Fax Number	:	765-741-0335

Provider Business Practice Location Address
First Line	:	2506 WILLOWBROOK PKWY STE 102A
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46205-1542
Country	:	US
Telephone Number	:	317-803-2270
Fax Number	:	317-217-1769

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/16/2008
Last Update Date	:	01/27/2020

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