Basic Information
| Provider Information | |||||||||
| NPI: | 1942283510 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CUDIAMAT | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | CARMEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 MEMORIAL SQ STE 50 | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461401357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174686270 | ||||||||
| FaxNumber: | 3174686268 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 W MCKENZIE RD STE H | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461401072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174622335 | ||||||||
| FaxNumber: | 3174622069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2005 | ||||||||
| LastUpdateDate: | 04/09/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01060435A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200311740 | 01 | IN | MEDICAID GROUP # | OTHER | 5717399 | 01 | IN | AETNA PIN# | OTHER | 000000383143 | 01 | IN | ANTHEM PIN# | OTHER | 200544230 | 05 | IN | MEDICAID |