Healthcare Provider Details

I. General information

NPI: 1568708428
Provider Name (Legal Business Name): FOWAD SHAHZAD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2012
Last Update Date: 05/22/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11109 PARKVIEW PLAZA DR
FORT WAYNE IN
46845-1701
US

IV. Provider business mailing address

2450 W HUNTING PARK AVE 3RD FLOOR
PHILADELPHIA PA
19129-1302
US

V. Phone/Fax

Practice location:
  • Phone: 260-266-2020
  • Fax: 260-266-2009
Mailing address:
  • Phone: 215-707-2433
  • Fax: 215-707-3677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC175555
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD207767
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01082951A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD449023
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01082951A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: