Provider Demographics
NPI:1780689257
Name:GHOSH, PRODYOT (MD)
Entity Type:Individual
Prefix:
First Name:PRODYOT
Middle Name:
Last Name:GHOSH
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 1:550 S LANDMARK AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-3239
Mailing Address - Country:US
Mailing Address - Phone:812-333-5973
Mailing Address - Fax:812-330-3681
Practice Address - Street 1:550 S LANDMARK AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-3239
Practice Address - Country:US
Practice Address - Phone:812-333-5973
Practice Address - Fax:812-330-3681
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043532A207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200019050Medicaid
INM400021736Medicare PIN
F98584Medicare UPIN
F98584Medicare UPIN