Provider Demographics
NPI:1508008020
Name:MANTRAVADI, MANASA G (MD)
Entity Type:Individual
Prefix:DR
First Name:MANASA
Middle Name:G
Last Name:MANTRAVADI
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 1:654 N SENATE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-3110
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:654 N SENATE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-3110
Practice Address - Country:US
Practice Address - Phone:812-240-9789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-30
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME113007208000000X
IN01075610A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201316090Medicaid
INP01512486OtherMEDICARE RR PTAN
IN266180590Medicare PIN
INP01512486OtherMEDICARE RR PTAN