Healthcare Provider Details

I. General information

NPI: 1003074451
Provider Name (Legal Business Name): ANANTACHOTE VIMUKTANANDANA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2008
Last Update Date: 05/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 W WALNUT ST APT D
INDIANAPOLIS IN
46202-3179
US

IV. Provider business mailing address

755 W WALNUT ST APT D
INDIANAPOLIS IN
46202-3179
US

V. Phone/Fax

Practice location:
  • Phone: 317-979-8409
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number11013134A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: