Basic Information
| Provider Information | |||||||||
| NPI: | 1265482988 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DODWANI | ||||||||
| FirstName: | KISHIN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 W UNIVERSITY AVE | ||||||||
| Address2: | RCS PROVIDER ENROLLMENT | ||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473033428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7657473111 | ||||||||
| FaxNumber: | 7657512757 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 ABRAHAM FLEXNER WAY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025874203 | ||||||||
| FaxNumber: | 5025874155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 06/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 01057137A | IN | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 38041 | KY | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 64101058 | 05 | KY | MEDICAID | 200448690A | 05 | IN | MEDICAID |