Provider Demographics
NPI:1124008768
Name:BATHINA, RAVINDRA (MD)
Entity Type:Individual
Prefix:
First Name:RAVINDRA
Middle Name:
Last Name:BATHINA
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:PO BOX 2505
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46801-2505
Mailing Address - Country:US
Mailing Address - Phone:260-432-2297
Mailing Address - Fax:260-436-4380
Practice Address - Street 1:7916 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-432-2297
Practice Address - Fax:260-436-4380
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029050207UN0901X, 207RI0011X, 207RC0000X
OH35046350207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Not Answered207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Not Answered207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000087419OtherANTHEM
IN058490HMedicare ID - Type Unspecified
INC02611Medicare UPIN