Provider Demographics
NPI:1194954560
Name:NAGESH, VINODHA (MD)
Entity type:Individual
Prefix:
First Name:VINODHA
Middle Name:
Last Name:NAGESH
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 1:330 N WABASH
Mailing Address - Street 2:STE G20
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2600
Mailing Address - Country:US
Mailing Address - Phone:765-660-7616
Mailing Address - Fax:765-651-7313
Practice Address - Street 1:1419 W BELLA DRIVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-5250
Practice Address - Country:US
Practice Address - Phone:765-660-7580
Practice Address - Fax:765-671-3508
Is Sole Proprietor?:No
Enumeration Date:2009-07-07
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01076633A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001012839OtherANTHEM
IN201356800Medicaid
IN201356800Medicaid