Healthcare Provider Details

I. General information

NPI: 1679662258
Provider Name (Legal Business Name): INDIRA S THIRKANNAD M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 E GRAY ST STE 766
LOUISVILLE KY
40202-1901
US

IV. Provider business mailing address

234 E GRAY ST STE 766
LOUISVILLE KY
40202-1901
US

V. Phone/Fax

Practice location:
  • Phone: 502-583-7337
  • Fax: 502-584-5437
Mailing address:
  • Phone: 502-583-7337
  • Fax: 502-584-5437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number40425
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number25MA10411200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: