Provider Demographics
NPI:1841465994
Name:ELANGO, SUBHA (MD)
Entity type:Individual
Prefix:
First Name:SUBHA
Middle Name:
Last Name:ELANGO
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 1:2330 S DIXON RD
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-6411
Mailing Address - Country:US
Mailing Address - Phone:765-455-5400
Mailing Address - Fax:765-865-3826
Practice Address - Street 1:2330 S DIXON RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-6411
Practice Address - Country:US
Practice Address - Phone:765-455-5400
Practice Address - Fax:765-865-3826
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57011197207Q00000X
IN01067440207Q00000X
IN01067440A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200967690Medicaid