Healthcare Provider Details

I. General information

NPI: 1568610632
Provider Name (Legal Business Name): JYOTHI VATTIKUTI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2008
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5980 W 71ST ST STE 102
INDIANAPOLIS IN
46278-1785
US

IV. Provider business mailing address

5013 MAKEFIELD CT
CARY NC
27519-7078
US

V. Phone/Fax

Practice location:
  • Phone: 317-388-0800
  • Fax: 317-388-0805
Mailing address:
  • Phone: 919-819-1987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number05008617A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: