Healthcare Provider Details

I. General information

NPI: 1285121574
Provider Name (Legal Business Name): SHASHANKA NETHI M.B.B.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2018
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 W 2ND ST
BLOOMINGTON IN
47403-2212
US

IV. Provider business mailing address

3403 E RAYMOND ST
INDIANAPOLIS IN
46203-4744
US

V. Phone/Fax

Practice location:
  • Phone: 812-333-4001
  • Fax: 812-333-4057
Mailing address:
  • Phone: 317-957-2000
  • Fax: 317-957-2050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01085108A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: