Healthcare Provider Details

I. General information

NPI: 1639120371
Provider Name (Legal Business Name): BANIPAL HOVHANESSIAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 12/22/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 W ALTO RD
KOKOMO IN
46902-4840
US

IV. Provider business mailing address

6626 E 75TH ST SUITE 500
INDIANAPOLIS IN
46250-2805
US

V. Phone/Fax

Practice location:
  • Phone: 765-455-2577
  • Fax: 765-455-0214
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: