Provider Demographics
NPI:1518493618
Name:MY TRAVEL CLINIC
Entity Type:Organization
Organization Name:MY TRAVEL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HOUMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-438-5529
Mailing Address - Street 1:4902 E THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-1905
Mailing Address - Country:US
Mailing Address - Phone:317-438-5529
Mailing Address - Fax:317-438-5929
Practice Address - Street 1:4902 E THOMPSON RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-1905
Practice Address - Country:US
Practice Address - Phone:317-438-5529
Practice Address - Fax:317-438-5929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-10
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042881A261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200007060Medicaid
IN200007060Medicaid
INF96545Medicare UPIN
INM100047140Medicare Oscar/Certification