Provider Demographics
NPI:1073542346
Name:GUTTIKONDA, DEEPAK (MD)
Entity Type:Individual
Prefix:
First Name:DEEPAK
Middle Name:
Last Name:GUTTIKONDA
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 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8075 N SHADELAND AVE STE 330
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2694
Practice Address - Country:US
Practice Address - Phone:317-353-7220
Practice Address - Fax:317-355-9672
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057922A2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01214609OtherRR MEDICARE PTAN
IN200456610Medicaid
IN7014504OtherAETNA
IN000000525348OtherANTHEM
IN000000525348OtherANTHEM
IN200456610Medicaid
IN7014504OtherAETNA
INP00421312Medicare PIN