Provider Demographics
NPI:1639173438
Name:BROGAN, THEODORE W (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:W
Last Name:BROGAN
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 1:6626 E 75TH ST
Mailing Address - Street 2:STE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3611 S REED RD
Practice Address - Street 2:STE 213
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3806
Practice Address - Country:US
Practice Address - Phone:765-865-6076
Practice Address - Fax:765-865-6077
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01048142207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200188340Medicaid
IN000000557418OtherANTHEM
IN266180779Medicare PIN
ININ1663084Medicare PIN
IN898220KMedicare PIN
ING78396Medicare UPIN
INM400015000Medicare PIN
IN200188340Medicaid