Provider Demographics
NPI:1093957110
Name:NUTHAKKI, PRITI M
Entity Type:Individual
Prefix:
First Name:PRITI
Middle Name:M
Last Name:NUTHAKKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:701 SUPERIOR AVE STE 2700
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-4037
Practice Address - Country:US
Practice Address - Phone:219-934-9813
Practice Address - Fax:219-934-9823
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-03
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036082683207R00000X, 207RG0100X, 207RI0008X
IN01080501A207R00000X, 207RT0003X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatology
No207RT0003XAllopathic & Osteopathic PhysiciansInternal MedicineTransplant Hepatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300015239Medicaid