Healthcare Provider Details

I. General information

NPI: 1962414508
Provider Name (Legal Business Name): ROBERT MARA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 ALBANY ST
BEECH GROVE IN
46107-1541
US

IV. Provider business mailing address

PO BOX 7112 DEPT. #31
INDIANAPOLIS IN
46207-7112
US

V. Phone/Fax

Practice location:
  • Phone: 317-783-8148
  • Fax:
Mailing address:
  • Phone: 317-802-3151
  • Fax: 317-870-0499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01045168
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: