Provider Demographics
NPI:1396004404
Name:CHITTICK, CONAN VON (MD)
Entity type:Individual
Prefix:
First Name:CONAN
Middle Name:VON
Last Name:CHITTICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1520 N SENATE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2213
Practice Address - Country:US
Practice Address - Phone:317-962-5423
Practice Address - Fax:317-962-6722
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-09
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01075578A207Q00000X, 207QS0010X
IN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN264430444OtherMEDICARE PTAN
IN000001029711OtherANTHEM PTAN
IN000001029731OtherANTHEM PTAN
IN201091300Medicaid