Provider Demographics
NPI:1891792818
Name:MARU, MAHENDRA C (MD)
Entity Type:Individual
Prefix:MR
First Name:MAHENDRA
Middle Name:C
Last Name:MARU
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 1:1930 E PARRISH AVE
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1443
Mailing Address - Country:US
Mailing Address - Phone:270-689-1919
Mailing Address - Fax:270-689-1990
Practice Address - Street 1:1930 E PARRISH AVE
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1443
Practice Address - Country:US
Practice Address - Phone:270-689-1919
Practice Address - Fax:270-689-1990
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33042207RN0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200145790Medicaid
IN000000067006OtherANTHEM PIN
KY64330426Medicaid
KYCJ7612OtherRAILROAD MEDICARE
KY000000067006OtherANTHEM
INCJ7612OtherRAILROAD MEDICARE
IN000000067006OtherANTHEM PIN
INCJ7612OtherRAILROAD MEDICARE
KY64330426Medicaid
IN189210Medicare PIN