Provider Demographics
NPI:1639161821
Name:CHOUDARY, JITHENDRA P (MD)
Entity Type:Individual
Prefix:DR
First Name:JITHENDRA
Middle Name:P
Last Name:CHOUDARY
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 1:1100 REID PKWY
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1157
Mailing Address - Country:US
Mailing Address - Phone:765-962-1337
Mailing Address - Fax:765-966-0858
Practice Address - Street 1:1100 REID PKWY
Practice Address - Street 2:SUITE 210
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1157
Practice Address - Country:US
Practice Address - Phone:765-962-1337
Practice Address - Fax:765-966-0858
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01065734A207RI0011X
OH35.074059207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000676851OtherANTHEM
IN200442130Medicaid
OH2262279Medicaid
INM400021447Medicare PIN
000000676851OtherANTHEM