Healthcare Provider Details

I. General information

NPI: 1396908455
Provider Name (Legal Business Name): PRAVEEN NALLAPAREDDY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 12/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 FIR ST UNIT 210
EAST CHICAGO IN
46312-8410
US

IV. Provider business mailing address

701 SUPERIOR AVE STE G
MUNSTER IN
46321-4037
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-6002
  • Fax:
Mailing address:
  • Phone: 219-922-3040
  • Fax: 219-922-3048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036.118276
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number01072083A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: