Healthcare Provider Details

I. General information

NPI: 1194617530
Provider Name (Legal Business Name): ISHAN DOMA
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2025
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 N SENATE BLVD
INDIANAPOLIS IN
46202-1239
US

IV. Provider business mailing address

25343 KINSALE PL
ALDIE VA
20105-3066
US

V. Phone/Fax

Practice location:
  • Phone: 317-962-2000
  • Fax:
Mailing address:
  • Phone: 571-639-1836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: