Provider Demographics
NPI:1962469510
Name:JETTY, PREETHAM (MD)
Entity Type:Individual
Prefix:
First Name:PREETHAM
Middle Name:
Last Name:JETTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PREETHAM
Other - Middle Name:
Other - Last Name:KONDLAPOODI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1210 A MEDICAL ARTS BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46011-3437
Practice Address - Country:US
Practice Address - Phone:765-298-4660
Practice Address - Fax:765-298-4926
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040154A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN4218217OtherAETNA
IN100120660Medicaid
IN000000557249OtherANTHEM
IN000000586512OtherANTHEM
INP01214600OtherRR MEDICARE PTAN
IN000000586512OtherANTHEM
IN100120660Medicaid
IN251320UMedicare PIN
IN258000AMedicare PIN
IN4218217OtherAETNA