Healthcare Provider Details

I. General information

NPI: 1538470935
Provider Name (Legal Business Name): MEGUMI SOBUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2010
Last Update Date: 06/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 SOUTH DR
INDIANAPOLIS IN
46202-5114
US

IV. Provider business mailing address

421 CANAL VIEW CIR APT A
INDIANAPOLIS IN
46202
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-8282
  • Fax:
Mailing address:
  • Phone: 443-570-4290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number11015634A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: