Provider Demographics
NPI:1619940970
Name:PANDIAN, SHOBANA
Entity Type:Individual
Prefix:DR
First Name:SHOBANA
Middle Name:
Last Name:PANDIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
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 1:10515 ILLINOIS RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46814
Practice Address - Country:US
Practice Address - Phone:260-373-9200
Practice Address - Fax:260-373-9219
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058626A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN146470C5OtherMEDICARE
IN200856050Medicaid
IN000000658068OtherANTHEM
INM400016110Medicare PIN
IN146470C5OtherMEDICARE