Healthcare Provider Details

I. General information

NPI: 1760707988
Provider Name (Legal Business Name): BHAVANA SIDDEGOWDA-BANGALORE MBBS.,MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2010
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 BARNHILL DR
INDIANAPOLIS IN
46202-5112
US

IV. Provider business mailing address

14765 HARVEST GLEN BLVD S
FISHERS IN
46037-9191
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-8438
  • Fax:
Mailing address:
  • Phone: 504-481-7009
  • 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 Code207RA0001X
TaxonomyAdvanced Heart Failure and Transplant Cardiology Physician
License Number01072248A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: