Provider Demographics
NPI:1497798516
Name:TEJADA, JUAN G (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:G
Last Name:TEJADA
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 1:250 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 1:1701 N SENATE BLVD
Practice Address - Street 2:ROOM 1204A
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1239
Practice Address - Country:US
Practice Address - Phone:317-962-6793
Practice Address - Fax:317-962-8281
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2021-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059717A2085R0202X, 2085R0204X, 2085N0700X, 2085N0700X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200495660Medicaid
IN219950IIIIMedicare PIN
IN200495660Medicaid
INP00316455Medicare PIN
IN959090N6Medicare PIN