Provider Demographics
NPI:1780002857
Name:MAZELLAN, KYLE J (MD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:J
Last Name:MAZELLAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:317-621-7588
Mailing Address - Fax:317-957-2749
Practice Address - Street 1:6964 HILLSDALE CT
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250
Practice Address - Country:US
Practice Address - Phone:317-621-9292
Practice Address - Fax:317-621-9299
Is Sole Proprietor?:No
Enumeration Date:2014-04-04
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN01080324A208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN260180B99OtherMEDICARE
IN300015972Medicaid
INP02085739OtherRAIDROAD MEDICARE