Healthcare Provider Details

I. General information

NPI: 1790912830
Provider Name (Legal Business Name): PRASANNA PONUGOTI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HOSPITAL LN STE 100
DANVILLE IN
46122-1993
US

IV. Provider business mailing address

1100 SOUTHFIELD DR STE 1370
PLAINFIELD IN
46168-4300
US

V. Phone/Fax

Practice location:
  • Phone: 317-745-7310
  • Fax: 317-745-7320
Mailing address:
  • Phone: 317-837-5566
  • Fax: 317-837-5580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2012020305
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01076182A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2012020305
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01076182A
License Number StateIN
# 5
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number01076182A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: