Provider Demographics
NPI:1790786127
Name:OO, KHIN MAR (MD)
Entity Type:Individual
Prefix:
First Name:KHIN
Middle Name:MAR
Last Name:OO
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 1:2121 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5100
Mailing Address - Country:US
Mailing Address - Phone:260-426-5431
Mailing Address - Fax:260-421-1092
Practice Address - Street 1:2121 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5100
Practice Address - Country:US
Practice Address - Phone:260-426-5431
Practice Address - Fax:260-421-1092
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044410A207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000081125OtherANTHEM
IN110123397OtherRAILROAD MEDICARE
IL6664OtherPHYSICIANS HEALTH PLAN
IN110123397OtherRAILROAD MEDICARE
IN200089420Medicare ID - Type Unspecified
IN000000081125OtherANTHEM