Provider Demographics
NPI:1770756009
Name:INDIANA INSTITUTE OF IMMUNOLOGY, ALLERGY AND ASTHMA, PC
Entity type:Organization
Organization Name:INDIANA INSTITUTE OF IMMUNOLOGY, ALLERGY AND ASTHMA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:MATESIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-450-6396
Mailing Address - Street 1:2216 W ALTO RD
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-4840
Mailing Address - Country:US
Mailing Address - Phone:765-450-6396
Mailing Address - Fax:765-450-6354
Practice Address - Street 1:2216 W ALTO RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-4840
Practice Address - Country:US
Practice Address - Phone:765-450-6396
Practice Address - Fax:765-450-6354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN256720Medicare PIN