Basic Information
| Provider Information | |||||||||
| NPI: | 1770718116 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAZDA | ||||||||
| FirstName: | MONICA | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6983 HILLSDALE CT | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178498350 | ||||||||
| FaxNumber: | 3175766311 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 N RITTER AVE STE 220 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462193046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177165600 | ||||||||
| FaxNumber: | 3177165618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2009 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0600X | 01074199A | IN | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 2084N0400X | 01074199A | IN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 201109640 | 05 | IN | MEDICAID |