Provider Demographics
NPI:1407182041
Name:KWATAMPORA, LILY (MD)
Entity Type:Individual
Prefix:
First Name:LILY
Middle Name:
Last Name:KWATAMPORA
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 1:2012 S MAIN ST
Mailing Address - Street 2:STE C
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-5200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2012 S MAIN ST
Practice Address - Street 2:STE C
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-5200
Practice Address - Country:US
Practice Address - Phone:574-500-2010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-01
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
IN01076257A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201354690Medicaid
IN201354690Medicaid