Provider Demographics
NPI:1659461150
Name:DYAMENAHALLI, UMESH
Entity Type:Individual
Prefix:
First Name:UMESH
Middle Name:
Last Name:DYAMENAHALLI
Suffix:
Gender:M
Credentials:
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 778912
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-8912
Mailing Address - Country:US
Mailing Address - Phone:317-777-6435
Mailing Address - Fax:317-777-6644
Practice Address - Street 1:621 MEMORIAL DR STE 612
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1085
Practice Address - Country:US
Practice Address - Phone:574-232-3325
Practice Address - Fax:574-232-3358
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01091288A207RA0002X, 2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No207RA0002XAllopathic & Osteopathic PhysiciansInternal MedicineAdult Congenital Heart Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201234550Medicaid
AR150260001Medicaid
5M657Medicare PIN