Provider Demographics
NPI:1821416207
Name:ROZA, KATHERINE ANNE (MD)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ANNE
Last Name:ROZA
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2651 E DISCOVERY PKWY
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-3412
Practice Address - Country:US
Practice Address - Phone:812-353-3719
Practice Address - Fax:812-353-3713
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA178928207RH0002X
390200000X
IN01093704A207R00000X, 207RG0300X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN090540A09OtherMEDICARE PTAN
IN1101380920OtherANTHEM PTAN
CAA178928OtherSTATE MEDICAL LICENSE
IN300092530Medicaid