Provider Demographics
NPI:1164475158
Name:KOYANI, ANANDKUMAR M (MD)
Entity Type:Individual
Prefix:
First Name:ANANDKUMAR
Middle Name:M
Last Name:KOYANI
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 1:303 S MAIN ST
Mailing Address - Street 2:SUITE 109
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544
Mailing Address - Country:US
Mailing Address - Phone:574-256-0235
Mailing Address - Fax:574-256-0235
Practice Address - Street 1:303 S MAIN ST
Practice Address - Street 2:SUITE 109
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544
Practice Address - Country:US
Practice Address - Phone:574-256-0235
Practice Address - Fax:574-256-0236
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01021660207R00000X
IN01021660A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000083739OtherANTHEM
INE33227Medicare UPIN
IN72880Medicare PIN