Provider Demographics
NPI:1376248823
Name:MUKONA, LAWRANCE TINOFARA (MD)
Entity Type:Individual
Prefix:
First Name:LAWRANCE
Middle Name:TINOFARA
Last Name:MUKONA
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 1:7165 CLEARVISTA WAY
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-4621
Mailing Address - Country:US
Mailing Address - Phone:317-621-5700
Mailing Address - Fax:
Practice Address - Street 1:7165 CLEARVISTA WAY
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-4621
Practice Address - Country:US
Practice Address - Phone:317-621-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-04
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN11023063A390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300076307Medicaid