Provider Demographics
NPI:1790912830
Name:PONUGOTI, PRASANNA (MD)
Entity Type:Individual
Prefix:
First Name:PRASANNA
Middle Name:
Last Name:PONUGOTI
Suffix:
Gender:F
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 SOUTHFIELD DR STE 1370
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-4300
Mailing Address - Country:US
Mailing Address - Phone:317-837-5566
Mailing Address - Fax:317-837-5580
Practice Address - Street 1:100 HOSPITAL LN STE 100
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IN
Practice Address - Zip Code:46122-1993
Practice Address - Country:US
Practice Address - Phone:317-745-7310
Practice Address - Fax:317-745-7320
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012020305207R00000X, 208M00000X
IN01076182A207R00000X, 208M00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1790912830Medicaid
MO139000104Medicare PIN