Provider Demographics
NPI:1043585946
Name:GANGADHAR, SHIVA PRASAD (MD)
Entity Type:Individual
Prefix:DR
First Name:SHIVA
Middle Name:PRASAD
Last Name:GANGADHAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6330 E 75TH ST STE 110
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2717
Mailing Address - Country:US
Mailing Address - Phone:317-588-7130
Mailing Address - Fax:317-588-7133
Practice Address - Street 1:6330 E 75TH ST
Practice Address - Street 2:STE 110
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2777
Practice Address - Country:US
Practice Address - Phone:317-588-7149
Practice Address - Fax:317-588-7150
Is Sole Proprietor?:No
Enumeration Date:2012-03-12
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01075188A208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201109490Medicaid
IN899980002Medicare PIN