Provider Demographics
NPI:1578558789
Name:TIWARI, KAMAL KUMAR (MD)
Entity Type:Individual
Prefix:
First Name:KAMAL
Middle Name:KUMAR
Last Name:TIWARI
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:PO BOX 5635
Mailing Address - Street 2:ATTN MANOJ KUMAR
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47407-5635
Mailing Address - Country:US
Mailing Address - Phone:812-337-5003
Mailing Address - Fax:812-337-5010
Practice Address - Street 1:2920 MCINTYRE DR
Practice Address - Street 2:SUITE 150
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-4221
Practice Address - Country:US
Practice Address - Phone:812-333-7246
Practice Address - Fax:812-333-4471
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01034945A207L00000X, 208VP0014X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100184000DMedicaid
IN100184000JMedicaid
IN000000076245OtherPMC ANTHEM
IN100184000AMedicaid
IN100184000CMedicaid
IN000000378036OtherSIA ANTHEM
IN100184000EMedicaid
IN100184000FMedicaid
IN000000076245OtherPMC ANTHEM
IN100184000AMedicaid
IN100184000DMedicaid
IN100184000FMedicaid