Provider Demographics
NPI:1699891085
Name:NEW CARLISLE FAMILY PRACTICE LLC
Entity type:Organization
Organization Name:NEW CARLISLE FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ASHOK
Authorized Official - Middle Name:P
Authorized Official - Last Name:DEVATHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-846-4000
Mailing Address - Street 1:432 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW CARLISLE
Mailing Address - State:OH
Mailing Address - Zip Code:45344-1427
Mailing Address - Country:US
Mailing Address - Phone:937-846-4000
Mailing Address - Fax:937-846-4004
Practice Address - Street 1:432 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW CARLISLE
Practice Address - State:OH
Practice Address - Zip Code:45344-1427
Practice Address - Country:US
Practice Address - Phone:937-846-4000
Practice Address - Fax:937-846-4004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35073686D207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2059883Medicaid
OH6405440001Medicare NSC
OH2059883Medicaid
OH9336641Medicare ID - Type Unspecified