Provider Demographics
NPI:1902184518
Name:BANAVALI, ASHTAMI VISHWANATH (MD)
Entity Type:Individual
Prefix:DR
First Name:ASHTAMI
Middle Name:VISHWANATH
Last Name:BANAVALI
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 1:430 N MONTE VISTA ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-4610
Mailing Address - Country:US
Mailing Address - Phone:580-421-1141
Mailing Address - Fax:580-421-1224
Practice Address - Street 1:430 N MONTE VISTA ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-4610
Practice Address - Country:US
Practice Address - Phone:580-421-1141
Practice Address - Fax:580-421-1224
Is Sole Proprietor?:No
Enumeration Date:2011-07-31
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP26486207R00000X
NY390200000X
OK32636207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program