Provider Demographics
NPI:1811072705
Name:FORKIN, MARY PAT (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:PAT
Last Name:FORKIN
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 1:15229 WESTFIELD BLVD
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-8000
Mailing Address - Country:US
Mailing Address - Phone:317-867-1236
Mailing Address - Fax:317-896-1299
Practice Address - Street 1:15229 WESTFIELD BLVD
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-8000
Practice Address - Country:US
Practice Address - Phone:317-867-1236
Practice Address - Fax:317-896-1299
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035037207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200009030Medicaid
IN151560JJJMedicare PIN
IN200009030Medicaid
INC46080Medicare UPIN
080158496Medicare PIN