Provider Demographics
NPI:1225365208
Name:MANTHENA, SWAPNA (MD)
Entity Type:Individual
Prefix:
First Name:SWAPNA
Middle Name:
Last Name:MANTHENA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6210 E HIGHWAY 290
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-1142
Mailing Address - Country:US
Mailing Address - Phone:512-483-9596
Mailing Address - Fax:512-406-6216
Practice Address - Street 1:901 CRYSTAL FALLS PKWY
Practice Address - Street 2:SUITE 150
Practice Address - City:LEANDER
Practice Address - State:TX
Practice Address - Zip Code:78641-1922
Practice Address - Country:US
Practice Address - Phone:512-259-2198
Practice Address - Fax:512-406-7374
Is Sole Proprietor?:No
Enumeration Date:2009-11-11
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57-016811390200000X
TXP2487207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX310069502Medicaid
TX310069503Medicaid
TX360418YKXYMedicare PIN
TX310069502Medicaid