Healthcare Provider Details

I. General information

NPI: 1194410951
Provider Name (Legal Business Name): MINKAH BECKTEMBA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2023
Last Update Date: 04/07/2023
Certification Date: 04/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 HUDSON ST
INDIANAPOLIS IN
46202-2532
US

IV. Provider business mailing address

634 COBBLESTONE RD
AVON IN
46123-8749
US

V. Phone/Fax

Practice location:
  • Phone: 317-992-6555
  • Fax:
Mailing address:
  • Phone: 317-992-9655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: