Provider Demographics
NPI:1245287713
Name:GOLLAMUDI, RADHARANI S (MD)
Entity type:Individual
Prefix:
First Name:RADHARANI
Middle Name:S
Last Name:GOLLAMUDI
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 1:5150 SHELBYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-2601
Mailing Address - Country:US
Mailing Address - Phone:317-782-1577
Mailing Address - Fax:888-366-7577
Practice Address - Street 1:5150 SHELBYVILLE RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-2601
Practice Address - Country:US
Practice Address - Phone:317-782-1577
Practice Address - Fax:888-366-7577
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY238672207R00000X
FLME109538207R00000X
IN01072789A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFB967YOtherMEDICARE
IN201173130Medicaid
FLFB967YOtherMEDICARE