Provider Demographics
NPI:1497925572
Name:RAJANAHALLI, PRAVEEN (MD)
Entity Type:Individual
Prefix:
First Name:PRAVEEN
Middle Name:
Last Name:RAJANAHALLI
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 1:701 E COUNTY LINE RD STE 210
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1071
Mailing Address - Country:US
Mailing Address - Phone:317-300-7424
Mailing Address - Fax:317-300-7976
Practice Address - Street 1:701 E COUNTY LINE RD STE 210
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143
Practice Address - Country:US
Practice Address - Phone:317-300-7424
Practice Address - Fax:317-300-7976
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11013162A208D00000X
IN01067143A208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200961530Medicaid