Basic Information
| Provider Information | |||||||||
| NPI: | 1447225818 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KRATHWOHL | ||||||||
| FirstName: | MITCHELL | ||||||||
| MiddleName: | DON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5550 S EAST ST STE C | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462271991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175344660 | ||||||||
| FaxNumber: | 3177824301 | ||||||||
| Practice Location | |||||||||
| Address1: | 5550 S EAST ST STE C | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462271991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175344660 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2019 | ||||||||
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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 | 207RI0200X | 01046293A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207R00000X | 01046293A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200206000 | 05 | IN | MEDICAID | 000000377245 | 01 | IN | ANTHEM ID NUMBER | OTHER | 000000720384 | 01 | IN | ANTHEM PROVIDER NUMBER FOR TIN 35-2030653 | OTHER |