Provider Demographics
NPI:1629003678
Name:MARDOS, JENNIFER M (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:MARDOS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:380 S JUNCTION XING
Practice Address - Street 2:SUITE 100
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074-7852
Practice Address - Country:US
Practice Address - Phone:317-399-3550
Practice Address - Fax:317-399-3555
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02004717A207Q00000X
OH34.009993207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0056264Medicaid
IN201337360Medicaid
IN264430384Medicare PIN
OH0056264Medicaid
ILI43874Medicare UPIN
ILP00292451Medicare PIN
IL920540Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER