Healthcare Provider Details

I. General information

NPI: 1114271483
Provider Name (Legal Business Name): AHMED MOHAMMED IBRAHIM ELSABBAGH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2012
Last Update Date: 11/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8414 NAAB RD
INDIANAPOLIS IN
46260-1972
US

IV. Provider business mailing address

10330 N MERIDIAN ST # 300
INDIANAPOLIS IN
46290-1024
US

V. Phone/Fax

Practice location:
  • Phone: 317-338-7510
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number01079145A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number57.020814
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMTL003109
License Number StateDC
# 4
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number01079145A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: