Provider Demographics
NPI:1285121574
Name:NETHI, SHASHANKA (MBBS)
Entity type:Individual
Prefix:
First Name:SHASHANKA
Middle Name:
Last Name:NETHI
Suffix:
Gender:F
Credentials:MBBS
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:317-957-2050
Practice Address - Street 1:811 W 2ND ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2212
Practice Address - Country:US
Practice Address - Phone:812-333-4001
Practice Address - Fax:812-333-4057
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01085108A208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300052974Medicaid