Provider Demographics
NPI:1225260342
Name:BOMMISETTY, LOKENDER (MD)
Entity Type:Individual
Prefix:DR
First Name:LOKENDER
Middle Name:
Last Name:BOMMISETTY
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 709
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47547-0709
Mailing Address - Country:US
Mailing Address - Phone:937-829-8422
Mailing Address - Fax:
Practice Address - Street 1:3707 NEW VISION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1702
Practice Address - Country:US
Practice Address - Phone:937-829-8422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-24
Last Update Date:2016-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT1973732085R0202X
IN01073618A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology