Provider Demographics
NPI:1205929510
Name:TIWARI, AJIT KUMAR (MD)
Entity type:Individual
Prefix:
First Name:AJIT
Middle Name:KUMAR
Last Name:TIWARI
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 1:3700 N EVERBROOK LN
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-5269
Mailing Address - Country:US
Mailing Address - Phone:765-281-1181
Mailing Address - Fax:765-282-4768
Practice Address - Street 1:3700 N EVERBROOK LN
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-5269
Practice Address - Country:US
Practice Address - Phone:765-281-1181
Practice Address - Fax:765-282-4768
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039897A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100094420EMedicaid
IN180027935OtherRR MEDICARE
IN000000219038OtherBLUE CROSS & BLUE SHIELD
IL036119147OtherSTATE LICENSE
IN000000219038OtherANTHEM BLUE CROSS
IN10236450000OtherTRICARE
IN100094420EMedicaid
IL036119147OtherSTATE LICENSE