Healthcare Provider Details

I. General information

NPI: 1114587623
Provider Name (Legal Business Name): DR. RANGARAJAN PURUSHOTHAMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 UNIVERSITY BLVD RM 663
INDIANAPOLIS IN
46202-5149
US

IV. Provider business mailing address

3841 GABLE LANE DR APT 537
INDIANAPOLIS IN
46228-3391
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-1866
  • Fax:
Mailing address:
  • Phone: 501-301-4416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number74045
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: