Provider Demographics
NPI:1497844278
Name:OOMMEN, KOSHY (MD)
Entity Type:Individual
Prefix:DR
First Name:KOSHY
Middle Name:
Last Name:OOMMEN
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 1:747 E COUNTY LINE RD STE B
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1082
Mailing Address - Country:US
Mailing Address - Phone:317-789-9600
Mailing Address - Fax:317-789-0600
Practice Address - Street 1:747 E COUNTY LINE RD STE B
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1082
Practice Address - Country:US
Practice Address - Phone:317-789-9600
Practice Address - Fax:317-789-0600
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058502A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01045880OtherRAILROAD MEDICARE
INP00117066OtherRR MEDICARE
IN000000333114OtherCOMMERCIAL
INP00117066OtherRR MEDICARE
IN200470370Medicaid
215950DMedicare ID - Type Unspecified
IN000000333114OtherCOMMERCIAL
IN200470370Medicaid