Provider Demographics
NPI:1689813073
Name:TENNENHOUSE, DEREK LEWIS (MD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:LEWIS
Last Name:TENNENHOUSE
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 1:1200 W CARMEL DR
Mailing Address - Street 2:#103
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-8707
Mailing Address - Country:US
Mailing Address - Phone:317-796-3897
Mailing Address - Fax:
Practice Address - Street 1:1200 W CARMEL DR
Practice Address - Street 2:#103
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-8707
Practice Address - Country:US
Practice Address - Phone:317-796-3897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-10
Last Update Date:2017-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056104C207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200374530Medicaid
IN200374530Medicaid