Provider Demographics
NPI:1255394805
Name:DAMODARAN, ATIMANAPARAMPIL N (MD)
Entity type:Individual
Prefix:
First Name:ATIMANAPARAMPIL
Middle Name:N
Last Name:DAMODARAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ATIMAN
Other - Middle Name:N
Other - Last Name:DAMODARAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:187 WEXFORD RD
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-8038
Mailing Address - Country:US
Mailing Address - Phone:574-806-4938
Mailing Address - Fax:
Practice Address - Street 1:187 WEXFORD RD
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46385-8038
Practice Address - Country:US
Practice Address - Phone:574-806-4938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028450A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1255394805OtherNPI NUMBER
IN000000672956OtherANTHEMPROVIDER NUMBER
9226652OtherCIGNA ID NUMBER
INM400023747OtherMEDICARE PTAN NUMBER
IN100225120Medicaid
IN1255394805OtherNPI NUMBER