Basic Information
| Provider Information | |||||||||
| NPI: | 1174797179 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | EAGAM | ||||||||
| FirstName: | MAMATA | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6920 POINTE INVERNESS WAY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468047934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604793513 | ||||||||
| FaxNumber: | 2604793520 | ||||||||
| Practice Location | |||||||||
| Address1: | 902 PROVIDENT DRIVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | WARSAW | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465803379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742698338 | ||||||||
| FaxNumber: | 5742698339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2008 | ||||||||
| LastUpdateDate: | 10/10/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 02004718A | IN | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | OS14468 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.