Provider Demographics
NPI:1528337847
Name:AVANTI AYUSH
Entity type:Organization
Organization Name:AVANTI AYUSH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SUBODHU
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:432-336-0700
Mailing Address - Street 1:237 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:FORT STOCKTON
Mailing Address - State:TX
Mailing Address - Zip Code:79735-2531
Mailing Address - Country:US
Mailing Address - Phone:432-336-0700
Mailing Address - Fax:432-336-0704
Practice Address - Street 1:237 W 21ST ST
Practice Address - Street 2:
Practice Address - City:FORT STOCKTON
Practice Address - State:TX
Practice Address - Zip Code:79735-2531
Practice Address - Country:US
Practice Address - Phone:432-336-0700
Practice Address - Fax:432-336-0704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-15
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4945207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty