Provider Demographics
NPI:1952619348
Name:MUDALAGIRI GOWDA, SUNITHA VALAMBIGE (MD)
Entity Type:Individual
Prefix:DR
First Name:SUNITHA
Middle Name:VALAMBIGE
Last Name:MUDALAGIRI GOWDA
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 1:3403 E RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46203-4744
Mailing Address - Country:US
Mailing Address - Phone:317-957-2000
Mailing Address - Fax:
Practice Address - Street 1:2855 N KEYSTONE AVE STE 100
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46218-2790
Practice Address - Country:US
Practice Address - Phone:317-957-2300
Practice Address - Fax:317-957-2320
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-20
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01083183A208000000X
IL125056808208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300033318Medicaid