Basic Information
| Provider Information | |||||||||
| NPI: | 1578721379 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOMMINENI | ||||||||
| FirstName: | MAYA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2022 KELLE DR | ||||||||
| Address2: | |||||||||
| City: | CHESTERTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463048708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193643616 | ||||||||
| FaxNumber: | 2193643610 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 E US HIGHWAY 6 STE 300 | ||||||||
| Address2: | |||||||||
| City: | VALPARAISO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199836300 | ||||||||
| FaxNumber: | 2199836080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2008 | ||||||||
| LastUpdateDate: | 09/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 233477 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 2014-01557 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 01075747A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | P01373172 | 01 | NC | MEDICARE RR | OTHER |