Provider Demographics
NPI:1164838934
Name:FERNANDES, SUSHMITHA (MD)
Entity type:Individual
Prefix:
First Name:SUSHMITHA
Middle Name:
Last Name:FERNANDES
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 1:250 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 1:14645 HAZEL DELL RD STE 100
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46062-7067
Practice Address - Country:US
Practice Address - Phone:317-678-4300
Practice Address - Fax:317-678-4310
Is Sole Proprietor?:No
Enumeration Date:2014-07-01
Last Update Date:2025-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01096670A207R00000X
OH133736207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1100005931OtherANTHEM
IN300119091Medicaid