Provider Demographics
NPI:1386831865
Name:KONKLE, AMY D (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:D
Last Name:KONKLE
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 1:819 E 64TH ST
Mailing Address - Street 2:SUITE 220
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220
Mailing Address - Country:US
Mailing Address - Phone:317-254-3800
Mailing Address - Fax:317-254-3885
Practice Address - Street 1:819 E 64TH ST
Practice Address - Street 2:SUITE 220
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220
Practice Address - Country:US
Practice Address - Phone:317-254-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-28
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01022225A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
INB28768Medicare UPIN
352100Medicare PIN