Provider Demographics
NPI:1376657783
Name:KAWANISHI, HIDEKI (MD)
Entity Type:Individual
Prefix:
First Name:HIDEKI
Middle Name:
Last Name:KAWANISHI
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 1:515 S WOODSCREST DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5524
Mailing Address - Country:US
Mailing Address - Phone:812-333-8194
Mailing Address - Fax:812-333-8237
Practice Address - Street 1:515 S WOODSCREST DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-5524
Practice Address - Country:US
Practice Address - Phone:812-333-8194
Practice Address - Fax:812-333-8237
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059330A207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0000000368280OtherANTHEM
IN200502110Medicaid
H81988Medicare UPIN
IN200502110Medicaid