Provider Demographics
NPI:1629065867
Name:UDANI, EDWIN A (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:A
Last Name:UDANI
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 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:221 US HIGHWAY 41 STE 1
Practice Address - Street 2:
Practice Address - City:SCHERERVILLE
Practice Address - State:IN
Practice Address - Zip Code:46375-1277
Practice Address - Country:US
Practice Address - Phone:219-864-3950
Practice Address - Fax:219-864-3952
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001229A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100147500Medicaid
IL0090000854OtherBCBS GROUP NUMBER
IN140220NNNMedicare PIN
E29406Medicare UPIN