Healthcare Provider Details

I. General information

NPI: 1386438299
Provider Name (Legal Business Name): DHEERAJ CHINNAM MBBS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2025
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W 11TH ST RM 4000H-2
INDIANAPOLIS IN
46202-4108
US

IV. Provider business mailing address

350 W 11TH ST RM 4000H-2
INDIANAPOLIS IN
46202-4108
US

V. Phone/Fax

Practice location:
  • Phone: 317-278-0844
  • Fax: 317-491-6419
Mailing address:
  • Phone: 317-278-0844
  • Fax: 317-491-6419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number11024028A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: