Basic Information
| Provider Information | |||||||||
| NPI: | 1346248051 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEMBLA | ||||||||
| FirstName: | PREETI | ||||||||
| MiddleName: | NANAK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11109 PARKVIEW PLAZA DR # 117 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451701 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11109 PARKVIEW PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2606726620 | ||||||||
| FaxNumber: | 2606726639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 09/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 39332 | TN | N | Other Service Providers | Specialist | 207R00000X | 39332 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | MD0000039332 | TN | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 01066343 | IN | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 01066343A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200940150 | 05 | IN | MEDICAID |