Individual
MARY VAN KOOTEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
550 S LANDMARK AVE, BLOOMINGTON, IN 47403-3239
(812) 355-6900
(812) 333-5978
Mailing address
250 N SHADELAND AVE, INDIANAPOLIS, IN 46219-4959
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
01057928A
IN
207QA0505X
Adult Medicine Physician
01057928A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
090540396
MEDICARE PTAN
IN
05
—
200452880
—
IN
01
—
Q00228730
RAILROAD PTAN
IN
Enumeration date
06/16/2005
Last updated
09/09/2023
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