Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207KA0200X | Allergist | 01061619A | IN |
NPI | 1558336230 |
---|---|
Provider Name | Damir Matesic |
First Address | Kokomo, IN 46902-4840 |
Second Address | Kokomo, IN 46902-4840 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/02/2006 |
Last Update Date | 14/03/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
I12101 | (02) | IN |