Healthcare Provider Details

I. General information

NPI: 1508853102
Provider Name (Legal Business Name): DEEPIKA KAKKERA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 11/20/2023
Certification Date: 11/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 S MAIN ST
CROWN POINT IN
46307-8481
US

IV. Provider business mailing address

PO BOX 1000
DYER IN
46311-0800
US

V. Phone/Fax

Practice location:
  • Phone: 219-757-5887
  • Fax: 219-757-6481
Mailing address:
  • Phone: 219-864-2107
  • Fax: 219-864-2649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01053443A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number01053443A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: