Provider Demographics
NPI:1659509669
Name:INDRAKUMARAN, JUDY
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:
Last Name:INDRAKUMARAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4851 E PICKARD ST
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-2078
Mailing Address - Country:US
Mailing Address - Phone:989-775-1610
Mailing Address - Fax:989-775-1640
Practice Address - Street 1:4851 E PICKARD ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2078
Practice Address - Country:US
Practice Address - Phone:989-775-1610
Practice Address - Fax:989-775-1640
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301094609207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine