Provider Demographics
NPI:1427094796
Name:MAMMEN, INDIRA (MD)
Entity type:Individual
Prefix:
First Name:INDIRA
Middle Name:
Last Name:MAMMEN
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 1:4922 COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-9188
Mailing Address - Country:US
Mailing Address - Phone:262-375-2829
Mailing Address - Fax:262-375-8513
Practice Address - Street 1:4922 COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012-9188
Practice Address - Country:US
Practice Address - Phone:262-375-2829
Practice Address - Fax:262-375-8513
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21773207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30415000Medicaid
46044Medicare ID - Type Unspecified
B54789Medicare UPIN