Basic Information
| Provider Information | |||||||||
| NPI: | 1841297801 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONTRERAS | ||||||||
| FirstName: | MARIO | ||||||||
| MiddleName: | ROLANDO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5628 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479035628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654484319 | ||||||||
| FaxNumber: | 7654482921 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 SOUTH ST | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479043027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654484319 | ||||||||
| FaxNumber: | 7654482921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2005 | ||||||||
| LastUpdateDate: | 07/16/2007 | ||||||||
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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 | 207ZP0102X | 01036557A | IN | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 000000082509 | 01 | IN | ANTHEM | OTHER | CB5232 | 01 | IN | RAILROAD MEDICARE | OTHER |