Provider Demographics
NPI:1194771113
Name:SUBBARAO, MANGALORE JAIRAM (MD)
Entity type:Individual
Prefix:
First Name:MANGALORE
Middle Name:JAIRAM
Last Name:SUBBARAO
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 1:2022 KELLE DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-8708
Mailing Address - Country:US
Mailing Address - Phone:219-326-2312
Mailing Address - Fax:219-326-2584
Practice Address - Street 1:104 E CULVER RD
Practice Address - Street 2:SUITE 102
Practice Address - City:KNOX
Practice Address - State:IN
Practice Address - Zip Code:46534-2241
Practice Address - Country:US
Practice Address - Phone:574-772-1580
Practice Address - Fax:574-772-1581
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01041718208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100383520Medicaid
IN000000682354OtherANTHEM
INF69178Medicare UPIN
INM400030013Medicare PIN