Basic Information
| Provider Information | |||||||||
| NPI: | 1386813210 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAHLE | ||||||||
| FirstName: | JUDITH | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E. 75TH STREET | ||||||||
| Address2: | SUITE # 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173557199 | ||||||||
| FaxNumber: | 3173559022 | ||||||||
| Practice Location | |||||||||
| Address1: | 1303 N ARLINGTON AVE | ||||||||
| Address2: | SUITE # 2 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462198300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173599671 | ||||||||
| FaxNumber: | 3173599672 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2008 | ||||||||
| LastUpdateDate: | 09/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01067683A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200990950 | 05 | IN | MEDICAID | P01009918 | 01 | IN | RR MEDICARE PTAN | OTHER |