Provider Demographics
NPI:1891893491
Name:KORMAN, MUTENA B (MD)
Entity Type:Individual
Prefix:DR
First Name:MUTENA
Middle Name:B
Last Name:KORMAN
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 1:111 W 10TH ST STE 102
Mailing Address - Street 2:
Mailing Address - City:HOBART
Mailing Address - State:IN
Mailing Address - Zip Code:46342-5969
Mailing Address - Country:US
Mailing Address - Phone:219-942-4222
Mailing Address - Fax:219-942-4233
Practice Address - Street 1:111 W 10TH ST STE 102
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-5969
Practice Address - Country:US
Practice Address - Phone:219-942-4222
Practice Address - Fax:219-942-4233
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2011-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01055605A208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200402440Medicaid
IND93893Medicare UPIN
IN200402440Medicaid