Provider Demographics
NPI:1710257316
Name:MANDAVA, ANUPA (MD)
Entity Type:Individual
Prefix:DR
First Name:ANUPA
Middle Name:
Last Name:MANDAVA
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 1:1169 EASTERN PKWY STE 3323
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-1415
Mailing Address - Country:US
Mailing Address - Phone:718-300-1540
Mailing Address - Fax:
Practice Address - Street 1:1169 EASTERN PKWY STE 3323
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1415
Practice Address - Country:US
Practice Address - Phone:718-300-1540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-12
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS23781207W00000X, 207WX0107X
TN52580207W00000X, 207WX0107X
ARE9162207W00000X, 207WX0107X, 207WX0107X
KY50737207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100498500Medicaid
TNQ013565Medicaid
IN300008335Medicaid
MS02874370Medicaid
TN103I186805Medicare PIN