MEDICARE: LYNN J VATTATHARA 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
1	208M00000X	Hospitalist Physician	01094818A	IN
2	390200000X	Student in an Organized Health Care Education/Training Program
3	207Q00000X	Family Medicine Physician	01094818A	IN

General Provider Information

NPI Number	:	1720668957
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYNN J VATTATHARA MD

Provider Business Mailing Address
First Line	:	PO BOX 781076
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48278-1076
Country	:	US
Telephone Number	:	317-528-4800
Fax Number	:	317-865-1479

Provider Business Practice Location Address
First Line	:	6831 W 133RD AVE
Second Line	:
City	:	CEDAR LAKE
State	:	IN
Zip	:	46303-8989
Country	:	US
Telephone Number	:	219-374-5970
Fax Number	:	219-374-7505

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/12/2021
Last Update Date	:	06/10/2025

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