Provider Demographics
NPI:1831324011
Name:MOHTASHEMI, KEVIN (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:MOHTASHEMI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9998 CROSSPOINT BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-3307
Mailing Address - Country:US
Mailing Address - Phone:317-579-2150
Mailing Address - Fax:317-579-2130
Practice Address - Street 1:9998 CROSSPOINT BLVD STE 200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-3307
Practice Address - Country:US
Practice Address - Phone:317-579-2150
Practice Address - Fax:317-579-2130
Is Sole Proprietor?:No
Enumeration Date:2009-05-18
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012474922085R0202X
MDD701732085R0202X
NV160962085R0202X
DCMD0384322085R0202X
CAC1389732085R0202X
IN01080213A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1831324011Medicaid
NV1831324011Medicaid
CACA175984Medicare PIN
CACA175747Medicare PIN
CACB245222Medicare PIN