Healthcare Provider Details

I. General information

NPI: 1629301932
Provider Name (Legal Business Name): ISLAM AHMED GHONEIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2009
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8402 HARCOURT RD STE 500
INDIANAPOLIS IN
46260-2054
US

IV. Provider business mailing address

8402 HARCOURT RD STE 500
INDIANAPOLIS IN
46260-2054
US

V. Phone/Fax

Practice location:
  • Phone: 317-338-6701
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number01070263A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number01070263A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: