Healthcare Provider Details

I. General information

NPI: 1225235492
Provider Name (Legal Business Name): MICHAEL CONSTANCIO RESPICIO MAHINAY IV P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 12/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 MAIN ST #1282
MOUNT VERNON IN
47620
US

IV. Provider business mailing address

3325 YALE DR
EVANSVILLE IN
47711-7305
US

V. Phone/Fax

Practice location:
  • Phone: 812-549-6512
  • Fax:
Mailing address:
  • Phone: 812-549-6512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number05009818A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: