Provider Demographics
NPI:1699743849
Name:KURETH, CAMILLE M (MD)
Entity type:Individual
Prefix:DR
First Name:CAMILLE
Middle Name:M
Last Name:KURETH
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 1:707 E CEDAR ST
Mailing Address - Street 2:STE 200
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2057
Mailing Address - Country:US
Mailing Address - Phone:574-335-8700
Mailing Address - Fax:574-335-0760
Practice Address - Street 1:611 E DOUGLAS RD
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1464
Practice Address - Country:US
Practice Address - Phone:574-335-6242
Practice Address - Fax:574-335-6243
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01071180B208000000X
MI4301036427208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201067770Medicaid
MI4827848/10Medicaid
IN000000200925OtherBCBS - COMM PEDS
MI4827848/10Medicaid