1356485833 NPI number — SHIMOGA RAMAIAH PRAKASH M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356485833 NPI number — SHIMOGA RAMAIAH PRAKASH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRAKASH
Provider First Name:
SHIMOGA
Provider Middle Name:
RAMAIAH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PRAKASH
Provider Other First Name:
SHIMOGA
Provider Other Middle Name:
RUDRAMURTHY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1356485833
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
701 E COUNTY LINE RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
GREENWOOD
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46143-1072
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-885-2860
Provider Business Mailing Address Fax Number:
317-885-2869

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 E COUNTY LINE RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
GREENWOOD
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46143-1072
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-885-2860
Provider Business Practice Location Address Fax Number:
317-885-2869
Provider Enumeration Date:
02/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  01072406A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: 01072406A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 201163250 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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