Provider Demographics
NPI: | 1376506899 |
---|---|
Name: | MINDREBO, NORMAN (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | NORMAN |
Middle Name: | |
Last Name: | MINDREBO |
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 775985 |
Mailing Address - Street 2: | |
Mailing Address - City: | CHICAGO |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 60677-5985 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 317-770-6900 |
Mailing Address - Fax: | 317-770-6911 |
Practice Address - Street 1: | 14535A HAZEL DELL PKWY |
Practice Address - Street 2: | |
Practice Address - City: | CARMEL |
Practice Address - State: | IN |
Practice Address - Zip Code: | 46033-9401 |
Practice Address - Country: | US |
Practice Address - Phone: | 317-770-3777 |
Practice Address - Fax: | 317-770-1727 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-04-07 |
Last Update Date: | 2020-09-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IN | 01036857A | 207XX0005X, 207X00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | |
No | 207XX0005X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IN | 200102730 | Medicaid | |
IN | M400064052 | Medicare PIN | |
IN | 200102730 | Medicaid | |
IN | 221620B | Medicare PIN |