Provider Demographics
NPI:1043292337
Name:CHOWATTUKUNNEL, THOMAS J (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:CHOWATTUKUNNEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:711 W GARDNER DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-1821
Mailing Address - Country:US
Mailing Address - Phone:765-662-6257
Mailing Address - Fax:765-668-6797
Practice Address - Street 1:711 W GARDNER DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-1821
Practice Address - Country:US
Practice Address - Phone:765-662-6257
Practice Address - Fax:765-668-6797
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2021-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036896A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100383540Medicaid
IN100383540Medicaid
E89871Medicare UPIN