Provider Demographics
NPI:1750420279
Name:DETRANA, CELESTINE (MD)
Entity type:Individual
Prefix:
First Name:CELESTINE
Middle Name:
Last Name:DETRANA
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:PO BOX 88898
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-0898
Mailing Address - Country:US
Mailing Address - Phone:317-299-8072
Mailing Address - Fax:317-299-8073
Practice Address - Street 1:4220 ROLAND RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46228-3237
Practice Address - Country:US
Practice Address - Phone:317-299-8072
Practice Address - Fax:317-299-8073
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010405602084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ING20811Medicare UPIN
IN268220Medicare ID - Type Unspecified