Healthcare Provider Details

I. General information

NPI: 1124604616
Provider Name (Legal Business Name): SANJANA PRABHU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5317 E 16TH ST
INDIANAPOLIS IN
46218-4897
US

IV. Provider business mailing address

5317 E 16TH ST
INDIANAPOLIS IN
46218-4897
US

V. Phone/Fax

Practice location:
  • Phone: 463-232-7158
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01099766A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: