Provider Demographics
NPI:1134214240
Name:KAUTZMANN, SHANNA VERMA (MD)
Entity type:Individual
Prefix:DR
First Name:SHANNA
Middle Name:VERMA
Last Name:KAUTZMANN
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 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:574-647-2129
Mailing Address - Fax:
Practice Address - Street 1:6913 N MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-8039
Practice Address - Country:US
Practice Address - Phone:574-647-4540
Practice Address - Fax:574-647-2567
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058244A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200310830Medicaid
IN000000350808OtherANTHEM INSURANCE
IN200310830AMedicaid
INH12966Medicare UPIN