Provider Demographics
NPI:1497702039
Name:BRAHMAMDAM, ANANTHA LAKSHMI (MD)
Entity Type:Individual
Prefix:
First Name:ANANTHA
Middle Name:LAKSHMI
Last Name:BRAHMAMDAM
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:PO BOX 636256 CENTRAL CREDENTIALING
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6256
Mailing Address - Country:US
Mailing Address - Phone:513-585-5501
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:8240 NORTHCREEK DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45236-2377
Practice Address - Country:US
Practice Address - Phone:513-853-7555
Practice Address - Fax:513-853-7550
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-124514207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200883820Medicaid
SCG56681Medicaid
OH2565399Medicaid
INP00903550OtherRAILROAD MEDICARE PTAN
GA470444616AMedicaid
GA470444616AMedicaid
INM400017607Medicare PIN
I40152Medicare UPIN