Provider Demographics
NPI:1952477259
Name:MAMTANI, RAVINDER (MD)
Entity Type:Individual
Prefix:DR
First Name:RAVINDER
Middle Name:
Last Name:MAMTANI
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 1:19 CREEKSIDE RD
Mailing Address - Street 2:
Mailing Address - City:HOPEWELL JUNCTION
Mailing Address - State:NY
Mailing Address - Zip Code:12533-6047
Mailing Address - Country:US
Mailing Address - Phone:845-227-6054
Mailing Address - Fax:
Practice Address - Street 1:19 CREEKSIDE RD
Practice Address - Street 2:
Practice Address - City:HOPEWELL JUNCTION
Practice Address - State:NY
Practice Address - Zip Code:12533-6047
Practice Address - Country:US
Practice Address - Phone:845-227-6054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1723632083P0901X, 2083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF41540Medicare UPIN
NY05L821Medicare ID - Type Unspecified