Provider Demographics
NPI:1093718207
Name:AWASTY, VIVEK RAJAN (MD)
Entity Type:Individual
Prefix:
First Name:VIVEK
Middle Name:RAJAN
Last Name:AWASTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:VIVEK
Other - Middle Name:RAJAN
Other - Last Name:AWASTY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:L-3549
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43260-0001
Mailing Address - Country:US
Mailing Address - Phone:740-387-0894
Mailing Address - Fax:740-387-8416
Practice Address - Street 1:980 S PROSPECT ST
Practice Address - Street 2:SUITE 2
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-6225
Practice Address - Country:US
Practice Address - Phone:740-383-7250
Practice Address - Fax:740-387-8416
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2021-12-15
Deactivation Date:2005-05-23
Deactivation Code:
Reactivation Date:2006-06-09
Provider Licenses
StateLicense IDTaxonomies
OH35065197A207R00000X
OH35065197207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0922836Medicaid
OHF59339Medicare UPIN
OHH160190Medicare PIN
OH0922836Medicaid
OH0740592Medicare PIN