Provider Demographics
NPI:1114372489
Name:JALLI, SWETHA (MD)
Entity Type:Individual
Prefix:DR
First Name:SWETHA
Middle Name:
Last Name:JALLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7926 PRESTON HWY STE 106
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-3848
Practice Address - Country:US
Practice Address - Phone:029-644-3575
Practice Address - Fax:502-966-5948
Is Sole Proprietor?:No
Enumeration Date:2016-04-25
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY53021207Q00000X
KYR4318207Q00000X
390200000X
IN01086247A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN068010713OtherMEDICARE
KY7100498700Medicaid
KYK285420OtherKY MEDICARE
IN264430C92OtherMEDICARE
IN300024282Medicaid