Provider Demographics
NPI:1144424813
Name:MAKINO, KOTARO (MD)
Entity Type:Individual
Prefix:
First Name:KOTARO
Middle Name:
Last Name:MAKINO
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 6005
Mailing Address - Street 2:DEPT 196
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-6005
Mailing Address - Country:US
Mailing Address - Phone:317-567-2179
Mailing Address - Fax:317-567-2191
Practice Address - Street 1:8040 CLEARVISTA PKWY
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-5630
Practice Address - Country:US
Practice Address - Phone:317-567-2179
Practice Address - Fax:317-567-2191
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062209207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200868970Medicaid
IN168040GGMedicare PIN