Provider Demographics
NPI:1801899901
Name:PERRY, NICOLE SUZETTE (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:SUZETTE
Last Name:PERRY
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 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
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 1:100 TOWN CENTER RD S
Practice Address - Street 2:STE B
Practice Address - City:MOORESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46158-2321
Practice Address - Country:US
Practice Address - Phone:317-497-2300
Practice Address - Fax:317-497-2502
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040509A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000283023OtherANTHEM PROVIDER NUMBER
IN200130700Medicaid
INP01018478OtherRR MEDICARE
INM400053913Medicare PIN
IN200130700Medicaid
INF62259Medicare UPIN