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NPI Code Detail

MEDICARE: AYKARETHU O MAMMEN MD

MEDICARE: AYKARETHU O MAMMEN MD
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
1208600000XSurgery Physician20052WI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1417993791
Entity Type Code : Individual
Provider Name (Legal Business Name) : AYKARETHU O MAMMEN MD
Provider Business Mailing Address
First Line : 4922 COLUMBIA RD
Second Line :
City : CEDARBURG
State : WI
Zip : 53012-9188
Country : US
Telephone Number : 262-375-2829
Fax Number : 262-375-8513
Provider Business Practice Location Address
First Line : 4922 COLUMBIA RD
Second Line :
City : CEDARBURG
State : WI
Zip : 53012-9188
Country : US
Telephone Number : 262-375-2829
Fax Number : 262-375-8513
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/22/2006
Last Update Date : 07/08/2007

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Directions to “ AYKARETHU O MAMMEN MD” Practice Location

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