Healthcare Provider Details

I. General information

NPI: 1427094796
Provider Name (Legal Business Name): INDIRA MAMMEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4922 COLUMBIA RD
CEDARBURG WI
53012-9188
US

IV. Provider business mailing address

4922 COLUMBIA RD
CEDARBURG WI
53012-9188
US

V. Phone/Fax

Practice location:
  • Phone: 262-375-2829
  • Fax: 262-375-8513
Mailing address:
  • Phone: 262-375-2829
  • Fax: 262-375-8513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number21773
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: