Provider Demographics
NPI:1861467854
Name:BETINA, PADMANABHA RAO (MD, FCCP)
Entity Type:Individual
Prefix:DR
First Name:PADMANABHA
Middle Name:RAO
Last Name:BETINA
Suffix:
Gender:M
Credentials:MD, FCCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64619 ORCHARD DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-9121
Mailing Address - Country:US
Mailing Address - Phone:574-533-4003
Mailing Address - Fax:
Practice Address - Street 1:200 HIGH PARK AVE
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-4810
Practice Address - Country:US
Practice Address - Phone:312-479-8669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2012-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039980207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100114150Medicaid
IN000000089017OtherANTHEM INSURANCE
IN228140Medicare PIN
INF13957Medicare UPIN