Healthcare Provider Details

I. General information

NPI: 1780002857
Provider Name (Legal Business Name): KYLE J MAZELLAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2014
Last Update Date: 11/27/2023
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6964 HILLSDALE CT
INDIANAPOLIS IN
46250
US

IV. Provider business mailing address

6626 E 75TH ST STE 500
INDIANAPOLIS IN
46250-2890
US

V. Phone/Fax

Practice location:
  • Phone: 317-621-9292
  • Fax: 317-621-9299
Mailing address:
  • Phone: 317-621-7588
  • Fax: 317-957-2749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number01080324A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: