Provider Demographics
NPI:1114183449
Name:THEERTHAM, MUNI K (MD)
Entity Type:Individual
Prefix:
First Name:MUNI
Middle Name:K
Last Name:THEERTHAM
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 1:6626 E 75TH ST
Mailing Address - Street 2:STE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3500 S LAFOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3803
Practice Address - Country:US
Practice Address - Phone:765-776-3020
Practice Address - Fax:765-453-8111
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301091596207R00000X
IN01069020A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000724294OtherANTHEM
1114183449OtherRR PTAN
IN201025960Medicaid
IN201025960Medicaid
IN000000724294OtherANTHEM
ININ1663091Medicare PIN