Provider Demographics
NPI:1265729297
Name:PARUCHURI, POONAM (MD)
Entity type:Individual
Prefix:
First Name:POONAM
Middle Name:
Last Name:PARUCHURI
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 1:250 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 1:1633 N CAPITOL AVE
Practice Address - Street 2:STE 322
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1476
Practice Address - Country:US
Practice Address - Phone:317-962-2929
Practice Address - Fax:317-962-2070
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01075832A207Q00000X, 207QG0300X
IL0361.34392207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201313360Medicaid
IN264430345Medicare PIN