Provider Demographics
NPI:1841297801
Name:CONTRERAS, MARIO ROLANDO (MD)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:ROLANDO
Last Name:CONTRERAS
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:PO BOX 5628
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5628
Mailing Address - Country:US
Mailing Address - Phone:765-448-4319
Mailing Address - Fax:765-448-2921
Practice Address - Street 1:2400 SOUTH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-3027
Practice Address - Country:US
Practice Address - Phone:765-448-4319
Practice Address - Fax:765-448-2921
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036557A207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000082509OtherANTHEM
INCB5232OtherRAILROAD MEDICARE
IN000000082509OtherANTHEM
IN805950FMedicare ID - Type Unspecified
IN176600RMedicare ID - Type Unspecified