Healthcare Provider Details

I. General information

NPI: 1952619348
Provider Name (Legal Business Name): SUNITHA VALAMBIGE MUDALAGIRI GOWDA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2010
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2855 N KEYSTONE AVE STE 100
INDIANAPOLIS IN
46218-2790
US

IV. Provider business mailing address

3403 E RAYMOND ST
INDIANAPOLIS IN
46203-4744
US

V. Phone/Fax

Practice location:
  • Phone: 317-957-2300
  • Fax: 317-957-2320
Mailing address:
  • Phone: 317-957-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01083183A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: