Healthcare Provider Details

I. General information

NPI: 1922096692
Provider Name (Legal Business Name): STEVEN M INDRA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S PARK ST
MADISON WI
53715-1830
US

IV. Provider business mailing address

700 S PARK ST
MADISON WI
53715-1830
US

V. Phone/Fax

Practice location:
  • Phone: 608-258-6504
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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 StateOH
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number56747-21
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License NumberTL945
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: