Individual
MUNI K THEERTHAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
3500 S LAFOUNTAIN ST, KOKOMO, IN 46902-3803
(765) 776-3020
(765) 453-8111
Mailing address
6626 E 75TH ST, STE 500, INDIANAPOLIS, IN 46250-2805
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
01069020A
IN
207R00000X
Internal Medicine Physician
4301091596
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000724294
ANTHEM
IN
01
—
1114183449
RR PTAN
—
05
—
201025960
—
IN
Enumeration date
08/06/2008
Last updated
11/27/2023
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