Provider Demographics
NPI:1275593725
Name:TANTRI, DEVIPRASAD M (MD)
Entity Type:Individual
Prefix:DR
First Name:DEVIPRASAD
Middle Name:M
Last Name:TANTRI
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 1:2104 FRONT ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44221-3259
Mailing Address - Country:US
Mailing Address - Phone:330-923-3502
Mailing Address - Fax:330-923-3507
Practice Address - Street 1:2104 FRONT ST
Practice Address - Street 2:SUITE B
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44221-3259
Practice Address - Country:US
Practice Address - Phone:330-923-3502
Practice Address - Fax:330-923-3507
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-27
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-0407208200000X
OH35040407208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHA75801Medicare UPIN
OH0432023Medicare PIN
OH0328756Medicaid
OHTA0432021Medicare ID - Type UnspecifiedMEDICARE