Healthcare Provider Details

I. General information

NPI: 1134331606
Provider Name (Legal Business Name): SAILAJA DAMINENI OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8380 VIRGINIA ST
MERRILLVILLE IN
46410
US

IV. Provider business mailing address

9519 LUEBCKE LANE
CROWNPOINT IN
46307
US

V. Phone/Fax

Practice location:
  • Phone: 219-769-9009
  • Fax:
Mailing address:
  • Phone: 312-799-0050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number31004064A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: