Provider Demographics
NPI:1477504835
Name:MAHIDHARA, INDIRA (MD)
Entity Type:Individual
Prefix:
First Name:INDIRA
Middle Name:
Last Name:MAHIDHARA
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 1:73D WINTHROP AVE
Mailing Address - Street 2:PLAZA 114
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01843-3716
Mailing Address - Country:US
Mailing Address - Phone:978-686-3017
Mailing Address - Fax:978-685-4280
Practice Address - Street 1:73D WINTHROP AVE
Practice Address - Street 2:PLAZA 114
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01843-3716
Practice Address - Country:US
Practice Address - Phone:978-686-3017
Practice Address - Fax:978-685-4280
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA226631207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
96223OtherFALLON COMM HEALTH PLAN
J27866OtherBLUE CARE ELECT
4147095OtherMVP HEALTH CARE
AA49793OtherHARVARD PILGRAM HLTH CARE
MARE7659Medicare ID - Type Unspecified
RE7659Medicare ID - Type UnspecifiedB
AA49793OtherHARVARD PILGRAM HLTH CARE