Healthcare Provider Details

I. General information

NPI: 1770547788
Provider Name (Legal Business Name): NATHAN PRAHLOW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 12/28/2020
Certification Date: 12/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 W 16TH ST SUITE 4300
INDIANAPOLIS IN
46202-2207
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-963-7077
  • Fax: 317-963-7068
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number01053141A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: