Healthcare Provider Details

I. General information

NPI: 1013697606
Provider Name (Legal Business Name): MARYAM BINTE YASIN M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2023
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date: 02/21/2024
Reactivation Date: 02/21/2024

III. Provider practice location address

640 ESKENAZI AVE STE
INDIANAPOLIS IN
46202-5173
US

IV. Provider business mailing address

640 ESKENAZI AVE STE
INDIANAPOLIS IN
46202-5173
US

V. Phone/Fax

Practice location:
  • Phone: 317-278-5316
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: