Provider Demographics
NPI:1215691308
Name:LOUISVILLE RETINA PLLC
Entity type:Organization
Organization Name:LOUISVILLE RETINA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:ANUPA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANDAVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-300-1540
Mailing Address - Street 1:1169 EASTERN PKWY STE 3323
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-1415
Mailing Address - Country:US
Mailing Address - Phone:502-873-0900
Mailing Address - Fax:502-873-0950
Practice Address - Street 1:1169 EASTERN PKWY STE 3323
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1415
Practice Address - Country:US
Practice Address - Phone:718-300-1540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-26
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100779210Medicaid