Basic Information
| Provider Information | |||||||||
| NPI: | 1932377090 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KANTAWALA | ||||||||
| FirstName: | KARTIKEYA | ||||||||
| MiddleName: | PRAKASH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 714 N SENATE AVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462023763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177156401 | ||||||||
| FaxNumber: | 3177156454 | ||||||||
| Practice Location | |||||||||
| Address1: | 714 N SENATE AVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462023763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177156401 | ||||||||
| FaxNumber: | 3177156454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2008 | ||||||||
| LastUpdateDate: | 09/26/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 2010026612 | MO | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085P0229X | 01069498A | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0202X | 01069498A | IN | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 201029390 | 05 | IN | MEDICAID |