Provider Demographics
NPI:1164493623
Name:KANVINDE, MANGESH
Entity Type:Individual
Prefix:
First Name:MANGESH
Middle Name:
Last Name:KANVINDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:361 CROSS ROADS BLVD
Mailing Address - Street 2:
Mailing Address - City:COLD SPRING
Mailing Address - State:KY
Mailing Address - Zip Code:41076-2194
Mailing Address - Country:US
Mailing Address - Phone:859-474-0374
Mailing Address - Fax:
Practice Address - Street 1:361 CROSS ROADS BLVD
Practice Address - Street 2:
Practice Address - City:COLD SPRING
Practice Address - State:KY
Practice Address - Zip Code:41076
Practice Address - Country:US
Practice Address - Phone:859-474-0374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059611A208D00000X
OH35076521208D00000X, 2085R0202X
FLME96979208D00000X
KY39807208D00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000221371OtherUNISON
OH000000510664OtherANTHEM ID
OH2205536Medicaid
OH422454OtherWELLCARE
OH733744OtherBUCKEYE
OH7496427OtherAETNA
OHP00381873OtherRAILROAD MEDICARE
OH0304914OtherBCMH
OHP00600867OtherRAILROAD MEDICARE
OH000000510664OtherANTHEM ID
OH000000221371OtherUNISON
OHP00381873OtherRAILROAD MEDICARE
OH2205536Medicaid