Healthcare Provider Details

I. General information

NPI: 1134765993
Provider Name (Legal Business Name): BASIL VARELDZIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2019
Last Update Date: 11/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9125 NAUTICAL WATCH DR
INDIANAPOLIS IN
46236-9036
US

IV. Provider business mailing address

PO BOX 361655
INDIANAPOLIS IN
46236-1655
US

V. Phone/Fax

Practice location:
  • Phone: 317-919-2846
  • Fax:
Mailing address:
  • Phone: 317-919-2846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01036191A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number01036191A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number01036191A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: