Provider Demographics
NPI:1336307909
Name:MALLUR, SHILPA RAVI (MD)
Entity Type:Individual
Prefix:
First Name:SHILPA
Middle Name:RAVI
Last Name:MALLUR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHILPA
Other - Middle Name:CHANNABASAPPA
Other - Last Name:GOWDRA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
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:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7120 CLEARVISTA DR
Practice Address - Street 2:SUITE 2100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1621
Practice Address - Country:US
Practice Address - Phone:317-621-5676
Practice Address - Fax:317-621-5658
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01066431A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200963940Medicaid
INP01133607OtherMEDICARE RAILROAD
IN200963940Medicaid
IN263840AMedicare PIN