Healthcare Provider Details

I. General information

NPI: 1942208905
Provider Name (Legal Business Name): PRAKASH S BHOOPALAM M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 02/27/2025
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 W UNIVERSITY AVE SUITE 404
MUNCIE IN
47303
US

IV. Provider business mailing address

10520 ROXLEY BEND
CARMEL IN
46032
US

V. Phone/Fax

Practice location:
  • Phone: 765-231-9494
  • Fax: 765-587-4456
Mailing address:
  • Phone: 765-729-5829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number01040631A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01040631A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: