Basic Information
| Provider Information | |||||||||
| NPI: | 1124028881 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KEOLASY | ||||||||
| FirstName: | THEPPANYA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 E DUPONT RD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603739700 | ||||||||
| FaxNumber: | 2603739740 | ||||||||
| Practice Location | |||||||||
| Address1: | 2003 STULTS RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | HUNTINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467501291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603565424 | ||||||||
| FaxNumber: | 2603582090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2005 | ||||||||
| LastUpdateDate: | 08/31/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01058795 | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200956680 | 05 | IN | MEDICAID | 000000655775 | 01 | IN | ANTHEM | OTHER | 200502100A | 05 | IN | MEDICAID |