Healthcare Provider Details

I. General information

NPI: 1659684488
Provider Name (Legal Business Name): SHAMIR HAJI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2010
Last Update Date: 10/12/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11104 PARKVIEW CIRCLE DR STE 110
FORT WAYNE IN
46845-1673
US

IV. Provider business mailing address

3702 NEW VISION DR BLDG B
FORT WAYNE IN
46845-1703
US

V. Phone/Fax

Practice location:
  • Phone: 260-425-6780
  • Fax: 260-425-6789
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number244207
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number54810
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number54435
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number105661
License Number StateMN
# 5
Primary TaxonomyY
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License Number01082886A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: