Healthcare Provider Details

I. General information

NPI: 1114243573
Provider Name (Legal Business Name): MIKAEL DENISE HOWARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MIKAEL DENISE CALLOWAY

II. Dates (important events)

Enumeration Date: 04/10/2010
Last Update Date: 11/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52500 FIR RD
GRANGER IN
46530-8579
US

IV. Provider business mailing address

52500 FIR RD
GRANGER IN
46530-8579
US

V. Phone/Fax

Practice location:
  • Phone: 574-204-7050
  • Fax: 574-204-7047
Mailing address:
  • Phone: 574-204-7050
  • Fax: 574-204-7047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01074276A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier201249390
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: