Provider Demographics
NPI:1790999415
Name:MUTNAL, AMAR BASAVARAJ (MD)
Entity Type:Individual
Prefix:DR
First Name:AMAR
Middle Name:BASAVARAJ
Last Name:MUTNAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 378
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44871-0378
Mailing Address - Country:US
Mailing Address - Phone:419-609-1112
Mailing Address - Fax:419-502-3537
Practice Address - Street 1:5319 HOAG DR STE 240
Practice Address - Street 2:
Practice Address - City:SHEFFIELD VILLAGE
Practice Address - State:OH
Practice Address - Zip Code:44035-1493
Practice Address - Country:US
Practice Address - Phone:419-626-6161
Practice Address - Fax:419-502-3537
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.120264207X00000X, 207XS0114X, 207XX0005X
FLME108709207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery