Provider Demographics
NPI:1306995766
Name:TANTRI, AVINASH PRASAD (MD)
Entity type:Individual
Prefix:
First Name:AVINASH
Middle Name:PRASAD
Last Name:TANTRI
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 1:31 PORTER ST
Mailing Address - Street 2:PO BOX 548
Mailing Address - City:LAKEVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06039
Mailing Address - Country:US
Mailing Address - Phone:860-435-0072
Mailing Address - Fax:860-435-9831
Practice Address - Street 1:31 PORTER ST
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:CT
Practice Address - Zip Code:06039
Practice Address - Country:US
Practice Address - Phone:860-435-0072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT045161207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400001647Medicare PIN