Provider Demographics
NPI:1730194416
Name:PAMATMAT, EDNA (MD)
Entity type:Individual
Prefix:
First Name:EDNA
Middle Name:
Last Name:PAMATMAT
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 1:8003 CASTLEWAY DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-1946
Mailing Address - Country:US
Mailing Address - Phone:317-576-1335
Mailing Address - Fax:844-397-1311
Practice Address - Street 1:1901 W WESTERN AVE STE B
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46619-3570
Practice Address - Country:US
Practice Address - Phone:574-234-9033
Practice Address - Fax:844-397-1310
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-072396207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD89952Medicare UPIN