Provider Demographics
NPI:1679540991
Name:GARG, MUKESH (MD)
Entity type:Individual
Prefix:MR
First Name:MUKESH
Middle Name:
Last Name:GARG
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 1:707 CEDAR ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2057
Mailing Address - Country:US
Mailing Address - Phone:574-335-8700
Mailing Address - Fax:574-335-0760
Practice Address - Street 1:2349 LAKE AVE STE 99
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563
Practice Address - Country:US
Practice Address - Phone:574-948-5340
Practice Address - Fax:574-948-5494
Is Sole Proprietor?:No
Enumeration Date:2006-03-06
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE27641207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP02006928OtherRAIL ROAD MEDICARE
IN300004401Medicaid
ININ1041053OtherMEDICARE