Provider Demographics
NPI:1578523676
Name:JAMES, THEKKUMKATTIL D (MD)
Entity Type:Individual
Prefix:
First Name:THEKKUMKATTIL
Middle Name:D
Last Name:JAMES
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 1:1234 E DUPONT RD
Mailing Address - Street 2:SUITE1
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-7875
Mailing Address - Fax:260-373-9705
Practice Address - Street 1:2510 E DUPONT RD
Practice Address - Street 2:STE 200
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825
Practice Address - Country:US
Practice Address - Phone:260-489-6969
Practice Address - Fax:260-490-3939
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01034777B207QA0505X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000690072OtherANTHEM
IN100080860Medicaid
IN000000690072OtherANTHEM
C24518Medicare UPIN
IN100080860Medicaid