Provider Demographics
NPI:1114243573
Name:HOWARD, MIKAEL DENISE
Entity Type:Individual
Prefix:
First Name:MIKAEL
Middle Name:DENISE
Last Name:HOWARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIKAEL
Other - Middle Name:DENISE
Other - Last Name:CALLOWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:52500 FIR RD
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-8579
Mailing Address - Country:US
Mailing Address - Phone:574-204-7050
Mailing Address - Fax:574-204-7047
Practice Address - Street 1:52500 FIR RD
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-8579
Practice Address - Country:US
Practice Address - Phone:574-204-7050
Practice Address - Fax:574-204-7047
Is Sole Proprietor?:No
Enumeration Date:2010-04-10
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01074276A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201249390Medicaid
IN146470036Medicare PIN