Provider Demographics
NPI:1407020852
Name:TASHJIAN-GIBBS, MARCELLA MONTANTE (M,D,)
Entity Type:Individual
Prefix:
First Name:MARCELLA
Middle Name:MONTANTE
Last Name:TASHJIAN-GIBBS
Suffix:
Gender:F
Credentials:M,D,
Other - Prefix:
Other - First Name:MARCELLA
Other - Middle Name:MONTANTE
Other - Last Name:TASHJIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1200 W WHITE RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-4988
Mailing Address - Country:US
Mailing Address - Phone:877-668-5621
Mailing Address - Fax:
Practice Address - Street 1:2600 GREENBUSH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2477
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-16
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN01070668A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201062760Medicaid
IN000000763791OtherANTHEM PROVIDER NUMBER
INP01090895Medicare PIN
IN000000763791OtherANTHEM PROVIDER NUMBER