Provider Demographics
NPI:1457366171
Name:ROUHANA, RUDOLPH
Entity Type:Individual
Prefix:
First Name:RUDOLPH
Middle Name:
Last Name:ROUHANA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E. 75TH STREET
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 N POST RD
Practice Address - Street 2:SUITE 2
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-4225
Practice Address - Country:US
Practice Address - Phone:317-355-6780
Practice Address - Fax:317-355-6782
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026170A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100057800Medicaid
IN000000313002OtherANTHEM
IN100057800Medicaid
IN214200AMedicare PIN
IN000000313002OtherANTHEM