Provider Demographics
NPI:1104874452
Name:DEVANATHAN, SRINIVASAN (MD)
Entity type:Individual
Prefix:DR
First Name:SRINIVASAN
Middle Name:
Last Name:DEVANATHAN
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:260-266-6013
Mailing Address - Fax:
Practice Address - Street 1:8028 CARNEGIE BLVD.
Practice Address - Street 2:SUITE 600
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-5790
Practice Address - Country:US
Practice Address - Phone:260-969-7100
Practice Address - Fax:260-969-7263
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059028A207RC0200X, 207RS0012X
IN01059028207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200481860Medicaid
INP00867128OtherR.R. MEDICARE
IN000000670561OtherANTHEM
IN925060GGGGMedicare PIN
INP00867128OtherR.R. MEDICARE
INH92175Medicare UPIN