Provider Demographics
NPI:1174789564
Name:MANTRAVADI, AVINASH V (MD)
Entity type:Individual
Prefix:DR
First Name:AVINASH
Middle Name:V
Last Name:MANTRAVADI
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 1:8820 S MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46217-6057
Practice Address - Country:US
Practice Address - Phone:317-865-6700
Practice Address - Fax:317-865-6707
Is Sole Proprietor?:No
Enumeration Date:2008-08-05
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME112145207Y00000X
IL125053425207Y00000X
IN01072985A207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000836361OtherANTHEM PIN
IN201180760Medicaid
IN063220007Medicare PIN
INP01305250Medicare PIN