Provider Demographics
NPI:1235228818
Name:MOTHKUR, SHEILA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHEILA
Middle Name:
Last Name:MOTHKUR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 WABASH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-4364
Mailing Address - Country:US
Mailing Address - Phone:219-874-5333
Mailing Address - Fax:219-874-0254
Practice Address - Street 1:1501 WABASH ST STE 101
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-4364
Practice Address - Country:US
Practice Address - Phone:219-874-5333
Practice Address - Fax:219-874-0254
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037546174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200336540Medicaid
IN200336540Medicaid
IN183240Medicare PIN