Provider Demographics
NPI:1689777021
Name:NDAH, BONIFACE (MD)
Entity Type:Individual
Prefix:
First Name:BONIFACE
Middle Name:
Last Name:NDAH
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 1:9550 ZIONSVILLE RD
Mailing Address - Street 2:SUITE #200
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-1065
Mailing Address - Country:US
Mailing Address - Phone:317-872-0116
Mailing Address - Fax:317-874-1440
Practice Address - Street 1:9550 ZIONSVILLE RD
Practice Address - Street 2:SUITE #200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-1065
Practice Address - Country:US
Practice Address - Phone:317-872-0116
Practice Address - Fax:317-874-1440
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056768A207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN250832OtherINDIANA COMPREHENSIVE
H75615OtherMERCY HEALTH PLAN
IN200411290Medicaid
IN250832OtherANTHEM BLUE SHIELD
2000411290OtherCARESOURCE
3170605OtherAETNA
H75615Medicare UPIN
IN200411290Medicaid
IN250832OtherANTHEM BLUE SHIELD
IN197040Medicare ID - Type Unspecified