Healthcare Provider Details

I. General information

NPI: 1528022340
Provider Name (Legal Business Name): KIEREN J MATHER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 03/30/2020
Certification Date: 03/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 W WALNUT ST IB 424
INDIANAPOLIS IN
46202-5181
US

IV. Provider business mailing address

250 N SHADELAND AVE STE 200
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-944-8660
  • Fax:
Mailing address:
  • Phone: 317-962-3834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number01051373
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number01051373A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: