Provider Demographics
NPI:1538655709
Name:MASTICK, KELLEN (MD)
Entity Type:Individual
Prefix:
First Name:KELLEN
Middle Name:
Last Name:MASTICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:574-647-1840
Mailing Address - Fax:
Practice Address - Street 1:615 N MICHIGAN ST 1ST FL HOSPITALIST STE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1033
Practice Address - Country:US
Practice Address - Phone:574-647-3050
Practice Address - Fax:574-647-4320
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ND15248207R00000X
IN01087004A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300060015Medicaid
IN300060015Medicaid