Provider Demographics
NPI:1750677589
Name:GNANAPRAGASAM, PRADEEP (MD,)
Entity Type:Individual
Prefix:DR
First Name:PRADEEP
Middle Name:
Last Name:GNANAPRAGASAM
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:GNANAPRADEEP
Other - Middle Name:
Other - Last Name:GNANAPRAGASAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:
Practice Address - Street 1:3920 ST FRANCIS WAY STE 220
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4922
Practice Address - Country:US
Practice Address - Phone:765-428-5950
Practice Address - Fax:765-428-5951
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01075271A208100000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM47140142OtherMEDICARE
IN201292900Medicaid