Provider Demographics
NPI:1164884813
Name:NALLANI, PRAKASH
Entity type:Individual
Prefix:
First Name:PRAKASH
Middle Name:
Last Name:NALLANI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8851 SOUTHPOINTE DR STE A1
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-0805
Practice Address - Country:US
Practice Address - Phone:317-497-4386
Practice Address - Fax:317-203-5213
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01087407A207R00000X, 207RR0500X
WI66413207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100087869Medicaid
266180L32OtherMEDICARE PIN
IN300063672Medicaid
INQ00399544OtherRAILROAD MEDICARE