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NPI Code Detail

MEDICARE: MAMATA EAGAM DO

MEDICARE: MAMATA EAGAM DO
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1208000000XPediatrics Physician02004718AIN
2208000000XPediatrics PhysicianOS14468FL

General Provider Information

NPI Number : 1174797179
Entity Type Code : Individual
Provider Name (Legal Business Name) : MAMATA EAGAM DO
Provider Business Mailing Address
First Line : 6920 POINTE INVERNESS WAY
Second Line : SUITE 200
City : FORT WAYNE
State : IN
Zip : 46804-7934
Country : US
Telephone Number : 260-479-3513
Fax Number : 260-479-3520
Provider Business Practice Location Address
First Line : 902 PROVIDENT DRIVE
Second Line : SUITE A
City : WARSAW
State : IN
Zip : 46580-3379
Country : US
Telephone Number : 574-269-8338
Fax Number : 574-269-8339
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/22/2008
Last Update Date : 10/10/2019

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