Individual
PRANAV PRAKASH
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
2600 GREENBUSH ST, LAFAYETTE, IN 47904-2477
(765) 448-8000
Mailing address
250 N SHADELAND AVE, INDIANAPOLIS, IN 46219-4959
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
01075184A
IN
207Q00000X
Family Medicine Physician
125060949
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000977223
ANTHEM
IN
01
—
000001011883
ANTHEM PROVIDER NUMBER UNDER TIN 35-2030653
IN
05
—
201305970
—
IN
Enumeration date
07/29/2012
Last updated
02/17/2021
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