Provider Demographics
NPI:1013111475
Name:KODENCHERY, MIHAS MAMU (MD)
Entity Type:Individual
Prefix:DR
First Name:MIHAS
Middle Name:MAMU
Last Name:KODENCHERY
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 1:5800 BROADWAY
Mailing Address - Street 2:SUITE A-J
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-2601
Mailing Address - Country:US
Mailing Address - Phone:219-884-9185
Mailing Address - Fax:
Practice Address - Street 1:5800 BROADWAY
Practice Address - Street 2:SUITE A-J
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-2601
Practice Address - Country:US
Practice Address - Phone:219-884-9185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2014-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301087486207R00000X, 390200000X
IN01072452A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program