Provider Demographics
NPI:1124028881
Name:KEOLASY, THEPPANYA KA (MD)
Entity Type:Individual
Prefix:
First Name:THEPPANYA
Middle Name:KA
Last Name:KEOLASY
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:577 GEIGER DR STE C
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:IN
Practice Address - Zip Code:46783-8877
Practice Address - Country:US
Practice Address - Phone:260-672-5950
Practice Address - Fax:260-672-0939
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058795A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000655775OtherANTHEM
IN200502100AMedicaid
IN200956680Medicaid
IN200502100AMedicaid
IN200956680Medicaid
IN307800KMedicare PIN
I15366Medicare UPIN