Provider Demographics
NPI:1861448722
Name:PREMKUMAR, SUNITA (MD)
Entity Type:Individual
Prefix:
First Name:SUNITA
Middle Name:
Last Name:PREMKUMAR
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 1:6626 E. 75TH STREET
Mailing Address - Street 2:SUITE 500
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 1:2040 N SHADELAND AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-1711
Practice Address - Country:US
Practice Address - Phone:317-355-2800
Practice Address - Fax:317-355-2828
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061971A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200821720Medicaid
INP01014115OtherRR MEDICARE PTAN
IN000000487706OtherANTHEM
INP00331316OtherRR MEDICARE
INP01014115OtherRR MEDICARE
IN200821720Medicaid
INP00331316OtherRR MEDICARE
IN364529263OtherEIN
IN214380FMedicare PIN
IN200821720Medicaid
IN000000487706OtherANTHEM