Provider Demographics
NPI:1114021615
Name:NJINIMBAM, CHARLES G (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:G
Last Name:NJINIMBAM
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:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1026
Mailing Address - Country:US
Mailing Address - Phone:317-777-6435
Mailing Address - Fax:317-777-6644
Practice Address - Street 1:1701 N SENATE AVE
Practice Address - Street 2:A3162
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5306
Practice Address - Country:US
Practice Address - Phone:317-962-8174
Practice Address - Fax:317-962-1445
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010399762080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200229850Medicaid
TN1510091Medicaid
INM400041108Medicare PIN