Basic Information
| Provider Information | |||||||||
| NPI: | 1578523676 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JAMES | ||||||||
| FirstName: | THEKKUMKATTIL | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 E DUPONT RD | ||||||||
| Address2: | SUITE1 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603737875 | ||||||||
| FaxNumber: | 2603739705 | ||||||||
| Practice Location | |||||||||
| Address1: | 2510 E DUPONT RD | ||||||||
| Address2: | STE 200 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604896969 | ||||||||
| FaxNumber: | 2604903939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 09/25/2013 | ||||||||
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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 | 207QA0505X | 01034777B | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 207RC0200X | 01034777B | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 01034777B | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 000000690072 | 01 | IN | ANTHEM | OTHER | 100080860 | 05 | IN | MEDICAID |