Provider Demographics
NPI:1790806529
Name:KOKOMO NEUROLOGY CLINIC, INC.
Entity Type:Organization
Organization Name:KOKOMO NEUROLOGY CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JITENDRA
Authorized Official - Middle Name:N
Authorized Official - Last Name:SHARMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-453-0891
Mailing Address - Street 1:3611 S REED RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-3828
Mailing Address - Country:US
Mailing Address - Phone:765-453-0891
Mailing Address - Fax:765-453-1407
Practice Address - Street 1:3611 S REED RD
Practice Address - Street 2:SUITE 101
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3828
Practice Address - Country:US
Practice Address - Phone:765-453-0891
Practice Address - Fax:765-453-1407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10342122084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN364310Medicare ID - Type UnspecifiedINDIANA
INC24884Medicare UPIN