Provider Demographics
NPI:1114046455
Name:NUTHAKKI, PRASANTH (MD)
Entity Type:Individual
Prefix:DR
First Name:PRASANTH
Middle Name:
Last Name:NUTHAKKI
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:PO BOX 3039
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-0039
Mailing Address - Country:US
Mailing Address - Phone:937-985-4010
Mailing Address - Fax:
Practice Address - Street 1:701 SUPERIOR AVE STE B
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-4038
Practice Address - Country:US
Practice Address - Phone:219-333-4757
Practice Address - Fax:219-401-4757
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2021-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01071908A204C00000X, 208100000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201134860Medicaid