Individual
FARDAD MASSOUMI BAVIL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
7905 CALUMET AVE, MUNSTER, IN 46321-2549
(219) 836-3049
(219) 836-7295
Mailing address
PO BOX 781076, DETROIT, MI 48278-1076
(317) 528-4800
(317) 865-1479
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
01065755A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200932220
—
IN
Enumeration date
09/28/2007
Last updated
06/23/2023
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