Healthcare Provider Details

I. General information

NPI: 1013111475
Provider Name (Legal Business Name): MIHAS MAMU KODENCHERY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 02/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 BROADWAY SUITE A-J
MERRILLVILLE IN
46410-2601
US

IV. Provider business mailing address

5800 BROADWAY SUITE A-J
MERRILLVILLE IN
46410-2601
US

V. Phone/Fax

Practice location:
  • Phone: 219-884-9185
  • Fax:
Mailing address:
  • Phone: 219-884-9185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301087486
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301087486
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number01072452A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: