Healthcare Provider Details

I. General information

NPI: 1669430658
Provider Name (Legal Business Name): MELANIE K JOHANNESSOHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W 10TH ST
INDIANAPOLIS IN
46202-2859
US

IV. Provider business mailing address

PO BOX 637764
CINCINNATI OH
45263-7764
US

V. Phone/Fax

Practice location:
  • Phone: 317-630-7979
  • Fax: 317-630-2668
Mailing address:
  • Phone: 317-880-3939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01045603A
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01045603A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01045603A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: