Provider Demographics
NPI:1205444775
Name:OWOFADEJU, ANU A (NP)
Entity type:Individual
Prefix:
First Name:ANU
Middle Name:A
Last Name:OWOFADEJU
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:ANU
Other - Middle Name:A
Other - Last Name:ADE OWOFADEJU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8820 S MERIDIAN ST STE 225
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46217-6064
Practice Address - Country:US
Practice Address - Phone:317-865-6922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-21
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71010185A363LP0808X
IN28207520A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001420103OtherANTHEM PTAN
IN300042058Medicaid