Provider Demographics
NPI:1518427905
Name:MUTAMBUZE, JEAN WILSON (MD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:WILSON
Last Name:MUTAMBUZE
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 1:1120 W MICHIGAN ST # CL642
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5209
Mailing Address - Country:US
Mailing Address - Phone:317-278-2686
Mailing Address - Fax:317-278-2650
Practice Address - Street 1:550 UNIVERSITY BLVD RM 663
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:317-944-1866
Practice Address - Fax:317-715-6474
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-21
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11021974A390200000X
IN01093511A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program