Provider Demographics
NPI:1184632747
Name:ANDHOLE, INDIRA P (MD)
Entity Type:Individual
Prefix:DR
First Name:INDIRA
Middle Name:P
Last Name:ANDHOLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:INDIRA
Other - Middle Name:P
Other - Last Name:YENNURALINGAM
Other - Suffix:
Other - Last Name Type:Doing Business As
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-647-6326
Mailing Address - Fax:
Practice Address - Street 1:1881 CHICAGO ST
Practice Address - Street 2:
Practice Address - City:DEPERE
Practice Address - State:WI
Practice Address - Zip Code:54115
Practice Address - Country:US
Practice Address - Phone:920-403-8000
Practice Address - Fax:920-403-8204
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40289208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32593400Medicaid
WI32593400Medicaid
BY5988603OtherDEA NUMBER