Provider Demographics
NPI:1912998642
Name:KALLOOKULANGARA, MATHEW JOSE (MD)
Entity Type:Individual
Prefix:
First Name:MATHEW
Middle Name:JOSE
Last Name:KALLOOKULANGARA
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 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:615 N MICHIGAN ST FL 1
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1033
Practice Address - Country:US
Practice Address - Phone:574-647-3050
Practice Address - Fax:574-647-1094
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059944A207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200520890Medicaid
IN261970AOtherMEDICARE PTAN
IN200520890Medicaid
IN000000615173OtherBCBS MEMORIAL HOSPITALIST
IN200520890Medicaid
IN261970AMedicare PIN