Provider Demographics
NPI:1649319112
Name:IVATURI, MRUTHYAMJAYA (MD)
Entity type:Individual
Prefix:
First Name:MRUTHYAMJAYA
Middle Name:
Last Name:IVATURI
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 1524
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1941 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331-2833
Practice Address - Country:US
Practice Address - Phone:765-827-7703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035094A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
010021203OtherRAILROAD MEDICARE
IN100114890AMedicaid
1370988OtherUNITED MINE WORKERS
IN000000079486OtherANTHEM
311255083OtherCHAMPUS
311255083OtherCHAMPUS
C24706Medicare UPIN