Provider Demographics
NPI:1356485833
Name:PRAKASH, SHIMOGA RAMAIAH (MD)
Entity Type:Individual
Prefix:
First Name:SHIMOGA
Middle Name:RAMAIAH
Last Name:PRAKASH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SHIMOGA
Other - Middle Name:RUDRAMURTHY
Other - Last Name:PRAKASH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:701 E COUNTY LINE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1072
Mailing Address - Country:US
Mailing Address - Phone:317-885-2860
Mailing Address - Fax:317-885-2869
Practice Address - Street 1:701 E COUNTY LINE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1072
Practice Address - Country:US
Practice Address - Phone:317-885-2860
Practice Address - Fax:317-885-2869
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01072406A207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201163250Medicaid
IN065940054Medicare PIN