Healthcare Provider Details

I. General information

NPI: 1629165378
Provider Name (Legal Business Name): SREENIVAS P KAMATH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1855 S MAIN ST STE A
GOSHEN IN
46526-4853
US

IV. Provider business mailing address

1855 S MAIN ST STE A
GOSHEN IN
46526-4853
US

V. Phone/Fax

Practice location:
  • Phone: 574-533-7476
  • Fax: 574-533-7145
Mailing address:
  • Phone: 574-533-7476
  • Fax: 574-533-7145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number01064505A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: