Provider Demographics
NPI:1790742450
Name:MISKULIN, JUDIANN (MD)
Entity Type:Individual
Prefix:
First Name:JUDIANN
Middle Name:
Last Name:MISKULIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:757 MASSACHUSETTS AVE UNIT 402
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46204-1692
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:757 MASSACHUSETTS AVE UNIT 402
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46204-1692
Practice Address - Country:US
Practice Address - Phone:317-000-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061067A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000386158OtherANTHEM PIN
INP01824517OtherRR MEDICARE
IN200529890Medicaid
I10929Medicare UPIN
INP00366914Medicare PIN
IN000000386158OtherANTHEM PIN
IN266180913Medicare PIN