Provider Demographics
NPI:1336482496
Name:SHENOI, MITHUN MOHANA (MD)
Entity type:Individual
Prefix:
First Name:MITHUN
Middle Name:MOHANA
Last Name:SHENOI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MITHUN
Other - Middle Name:MOHANA
Other - Last Name:SHENOI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11104 PARKVIEW CIRCLE DRIVE SUITE 320
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845
Practice Address - Country:US
Practice Address - Phone:260-266-5300
Practice Address - Fax:260-266-5314
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01079692A208C00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300015291Medicaid