Provider Demographics
NPI:1013181387
Name:HERNANDEZ MONDRAGON, RUBEN HERNAN (MD)
Entity Type:Individual
Prefix:
First Name:RUBEN
Middle Name:HERNAN
Last Name:HERNANDEZ MONDRAGON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 - PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1040 WISHARD BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2872
Practice Address - Country:US
Practice Address - Phone:317-962-8893
Practice Address - Fax:317-962-2990
Is Sole Proprietor?:No
Enumeration Date:2008-04-17
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01065039A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200898960Medicaid
IN000000591255OtherANTHEM
IN200898960Medicaid
IN264430297Medicare PIN
IN000000591255OtherANTHEM
IN068010021Medicare PIN