Provider Demographics
NPI:1770909392
Name:MENTOR, EMMANUEL THIERRY
Entity type:Individual
Prefix:
First Name:EMMANUEL THIERRY
Middle Name:
Last Name:MENTOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 LAPORTE AVE
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-5801
Mailing Address - Country:US
Mailing Address - Phone:219-263-4977
Mailing Address - Fax:
Practice Address - Street 1:650 DICKINSON RD
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-3387
Practice Address - Country:US
Practice Address - Phone:219-926-7755
Practice Address - Fax:219-929-1885
Is Sole Proprietor?:No
Enumeration Date:2014-03-06
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN01073933A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program