Provider Demographics
NPI:1497869929
Name:MAHAJAN, RAVISH J (MD)
Entity Type:Individual
Prefix:
First Name:RAVISH
Middle Name:J
Last Name:MAHAJAN
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 4699
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-4699
Mailing Address - Country:US
Mailing Address - Phone:765-449-2732
Mailing Address - Fax:765-449-1196
Practice Address - Street 1:5 EXECUTIVE DR
Practice Address - Street 2:SUITE B1
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4867
Practice Address - Country:US
Practice Address - Phone:765-807-0531
Practice Address - Fax:765-807-0534
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061610A207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000390071OtherANTHEM PROVIDER NUMBER
IN200807890Medicaid
IN000000390071OtherANTHEM PROVIDER NUMBER
ING37521Medicare UPIN
IN815160NMedicare PIN