Provider Demographics
NPI:1447225818
Name:KRATHWOHL, MITCHELL D (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:D
Last Name:KRATHWOHL
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 UNIVERSITY BLVD # UH3005
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5149
Practice Address - Country:US
Practice Address - Phone:317-962-8851
Practice Address - Fax:317-962-5957
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01046293A207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000377245OtherANTHEM ID NUMBER
IN200206000Medicaid
IN000000720384OtherANTHEM PROVIDER NUMBER FOR TIN 35-2030653
INM400049853Medicare PIN
IN248420IMedicare PIN
IN000000377245OtherANTHEM ID NUMBER
ING83705Medicare UPIN