Healthcare Provider Details

I. General information

NPI: 1518895630
Provider Name (Legal Business Name): PRINCE ENE-OJO ETUH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3652 NEWBERRY RD
PLAINFIELD IN
46168-7366
US

IV. Provider business mailing address

3652 NEWBERRY RD
PLAINFIELD IN
46168-7366
US

V. Phone/Fax

Practice location:
  • Phone: 317-220-2209
  • Fax:
Mailing address:
  • Phone: 317-220-2209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberMATS-5308
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: