Healthcare Provider Details

I. General information

NPI: 1104742402
Provider Name (Legal Business Name): MANEESH BALLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 UNIVERSITY BLVD
INDIANAPOLIS IN
46202-5149
US

IV. Provider business mailing address

10717 LAKE SHASTA CT
FORT WAYNE IN
46804-6906
US

V. Phone/Fax

Practice location:
  • Phone: 317-944-5000
  • Fax:
Mailing address:
  • Phone: 760-889-5665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number7906-1465-8528
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: