MEDICARE: NICHOLAS REDILLA III

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	390200000X	Student in an Organized Health Care Education/Training Program	11024927A	IN

General Provider Information

NPI Number	:	1164236188
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS REDILLA III

Provider Business Mailing Address
First Line	:	1040 WISHARD BLVD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46202-2872
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1040 WISHARD BLVD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46202-2872
Country	:	US
Telephone Number	:	317-278-7930
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/03/2025
Last Update Date	:	05/22/2026

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Directions to “ NICHOLAS REDILLA III ” Practice Location

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