Healthcare Provider Details

I. General information

NPI: 1457347205
Provider Name (Legal Business Name): HERATCH O DOUMANIAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 S MAIN ST
CROWN POINT IN
46307-8481
US

IV. Provider business mailing address

55 E 86TH AVE
MERRILLVILLE IN
46410-6382
US

V. Phone/Fax

Practice location:
  • Phone: 219-757-6320
  • Fax: 219-738-6714
Mailing address:
  • Phone: 219-769-1670
  • Fax: 219-738-6714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number01021772
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: