Provider Demographics
NPI:1831339720
Name:BANERJEE, AMBAR (MD)
Entity type:Individual
Prefix:DR
First Name:AMBAR
Middle Name:
Last Name:BANERJEE
Suffix:
Gender:M
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 1:1801 N SENATE BLVD STE 635
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1212
Practice Address - Country:US
Practice Address - Phone:317-944-0960
Practice Address - Fax:317-688-2921
Is Sole Proprietor?:No
Enumeration Date:2009-03-04
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01073596A208600000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201212140Medicaid
IN000000865797OtherANTHEM PIN
IN233690031Medicare PIN