Basic Information
| Provider Information | |||||||||
| NPI: | 1144575960 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDEM | ||||||||
| FirstName: | DINESH LAXMINARA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 251420 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722251420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016868000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2600 FERRY ST | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479043055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7658387450 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2012 | ||||||||
| LastUpdateDate: | 11/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01078017A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | P27586 | MD | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | E-14762 | AR | N | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207R00000X | E-14762 | AR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000001094186 | 01 | IN | ANTHEM | OTHER |