Provider Demographics
NPI:1598772428
Name:AVENA, ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:AVENA
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 385
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:IN
Mailing Address - Zip Code:47882-0385
Mailing Address - Country:US
Mailing Address - Phone:812-268-6292
Mailing Address - Fax:
Practice Address - Street 1:2200 N SECTION ST
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IN
Practice Address - Zip Code:47882-7523
Practice Address - Country:US
Practice Address - Phone:812-268-6292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038723207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN110123778OtherRAILROAD MEDICARE
IN1003265760CMedicaid
IN023329800OtherFEDERAL BLACK LUNG
IN10780065OtherCAQH
IN1003265760CMedicaid
IN218860Medicare PIN