Healthcare Provider Details

I. General information

NPI: 1053491415
Provider Name (Legal Business Name): KARL D PRYOR JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 E RAYMOND ST
INDIANAPOLIS IN
46203-4744
US

IV. Provider business mailing address

3401 E RAYMOND ST
INDIANAPOLIS IN
46203-4744
US

V. Phone/Fax

Practice location:
  • Phone: 317-957-2100
  • Fax: 317-957-2120
Mailing address:
  • Phone: 317-957-2100
  • Fax: 317-957-2120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number40208
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01068714A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: