1356332001 NPI number — CAROL K FOSSO MD

Table of content: CAROL K FOSSO MD (NPI 1356332001)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356332001 NPI number — CAROL K FOSSO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FOSSO
Provider First Name:
CAROL
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FOSSO
Provider Other First Name:
CAROL
Provider Other Middle Name:
K
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1356332001
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
70 E 91ST ST STE 204
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46240-1564
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-872-4213
Provider Business Mailing Address Fax Number:
317-872-6388

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
70 E 91ST ST STE 204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46240-1564
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-872-4213
Provider Business Practice Location Address Fax Number:
317-872-6388
Provider Enumeration Date:
11/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207KA0200X , with the licence number:  1037197 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100132220 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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