Provider Demographics
NPI:1114500592
Name:VATTATHARA, KENN (MD)
Entity type:Individual
Prefix:DR
First Name:KENN
Middle Name:
Last Name:VATTATHARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BUILDING 52/ LAKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684
Mailing Address - Country:US
Mailing Address - Phone:423-439-8000
Mailing Address - Fax:423-439-2200
Practice Address - Street 1:720 45TH ST
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2818
Practice Address - Country:US
Practice Address - Phone:219-852-2513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-03
Last Update Date:2025-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361728062084P0800X
IN01095510A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry