Healthcare Provider Details

I. General information

NPI: 1457795205
Provider Name (Legal Business Name): SHANTHAKUMARI PRAVEEN JINNUR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2013
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 PENNSYLVANIA PKWY
CARMEL IN
46280-2301
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-944-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number01098883A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number01098883A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01098883A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberTEP9101
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: