Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 01075433A | IN |
N | 207Q00000X | Family Doctor | N9976 | TX |
Y | 207QG0300X | Family Doctor - Geriatric Medicine | 01075433A | IN |
N | 207QG0300X | Family Doctor - Geriatric Medicine | N9976 | TX |
NPI | 1013249838 |
---|---|
Provider Name | Kamal C Wagle |
First Address | Indianapolis, IN 46219-4959 |
Second Address | Indianapolis, IN 46202-5187 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/02/2010 |
Last Update Date | 12/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
201291250 | (05) | IN |