Healthcare Provider Details

I. General information

NPI: 1770004954
Provider Name (Legal Business Name): MICHAEL GIFFEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MICHAEL SHENEFIELD DO

II. Dates (important events)

Enumeration Date: 06/28/2017
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8150 OAKLANDON RD STE 130
INDIANAPOLIS IN
46236-9554
US

IV. Provider business mailing address

6626 E 75TH ST STE 500
INDIANAPOLIS IN
46250-2890
US

V. Phone/Fax

Practice location:
  • Phone: 317-621-1111
  • Fax: 317-621-1110
Mailing address:
  • Phone: 315-621-7547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11019293A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02005461A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: