Provider Demographics
NPI:1356318414
Name:PRALL, RICHARD THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:THOMAS
Last Name:PRALL
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 1:8649 BAY COLONY DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46234-2912
Mailing Address - Country:US
Mailing Address - Phone:317-297-7519
Mailing Address - Fax:
Practice Address - Street 1:8649 BAY COLONY DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46234-2912
Practice Address - Country:US
Practice Address - Phone:317-297-7519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01053415A207R00000X, 207RG0100X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200303800Medicaid
IN000000600490OtherBLUE SHIELD
IN862280DDDMedicare PIN
IN142190TTMedicare PIN
IN131180IIMedicare PIN
G47051Medicare UPIN
IN214040EMedicare ID - Type Unspecified