Provider Demographics
NPI:1447263173
Name:NYONGANI, PAUL (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:NYONGANI
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 1:6111 HARRISON ST
Mailing Address - Street 2:#252
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410
Mailing Address - Country:US
Mailing Address - Phone:219-980-1348
Mailing Address - Fax:219-980-1151
Practice Address - Street 1:6111 HARRISON ST
Practice Address - Street 2:#252
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410
Practice Address - Country:US
Practice Address - Phone:219-980-1348
Practice Address - Fax:219-980-1151
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029603208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100212680Medicaid
IN704280Medicare ID - Type Unspecified
IN100212680Medicaid