Provider Demographics
NPI:1174797179
Name:EAGAM, MAMATA (DO)
Entity type:Individual
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First Name:MAMATA
Middle Name:
Last Name:EAGAM
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Gender:F
Credentials:DO
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Mailing Address - Street 1:6920 POINTE INVERNESS WAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-479-3513
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:902 PROVIDENT DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3379
Practice Address - Country:US
Practice Address - Phone:574-269-8338
Practice Address - Fax:574-269-8339
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2019-10-10
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Provider Licenses
StateLicense IDTaxonomies
IN02004718A208000000X
FLOS14468208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics