Provider Demographics
NPI:1194726927
Name:MANTRAVADI, RAO VP (MD)
Entity type:Individual
Prefix:
First Name:RAO
Middle Name:VP
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 1:7910 W JEFFERSON BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4159
Mailing Address - Country:US
Mailing Address - Phone:260-436-4116
Mailing Address - Fax:260-436-1878
Practice Address - Street 1:7910 W JEFFERSON BLVD STE 110
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4159
Practice Address - Country:US
Practice Address - Phone:260-436-4116
Practice Address - Fax:260-436-1878
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01032697A2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100321360Medicaid
MI1194726927Medicaid
OH0573026Medicaid
IND95412Medicare UPIN
IN100321360Medicaid
MI1194726927Medicaid