Provider Demographics
NPI:1407313489
Name:MATHAI, MICAH T (MD)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:T
Last Name:MATHAI
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 1:13100 E 136TH ST STE 2400
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-9810
Mailing Address - Country:US
Mailing Address - Phone:317-328-6620
Mailing Address - Fax:
Practice Address - Street 1:13100 E 136TH ST STE 2400
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-9810
Practice Address - Country:US
Practice Address - Phone:317-328-6620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01089614A207V00000X, 207V00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program