Provider Demographics
NPI:1134562952
Name:WARREN, TENDEUKAI RATIDZO (MD)
Entity type:Individual
Prefix:
First Name:TENDEUKAI
Middle Name:RATIDZO
Last Name:WARREN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TENDEUKAI
Other - Middle Name:RATIDZO
Other - Last Name:HUNGWE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:SUITE 130 - PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:317-962-3886
Mailing Address - Fax:
Practice Address - Street 1:1701 N SENATE BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1239
Practice Address - Country:US
Practice Address - Phone:317-962-3886
Practice Address - Fax:317-962-5492
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-10
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01075790A207P00000X
IN11017207A390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201171870Medicaid
INP01718891Medicare PIN
IN264430343Medicare PIN