Healthcare Provider Details

I. General information

NPI: 1245323120
Provider Name (Legal Business Name): LALITHA B MUTNAL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 S JACKSON ST
FRANKFORT IN
46041-3313
US

IV. Provider business mailing address

9588 VALPARAISO CT
INDIANAPOLIS IN
46268-1130
US

V. Phone/Fax

Practice location:
  • Phone: 765-656-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number01055973A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: