Individual
RAO VP MANTRAVADI
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
7910 W JEFFERSON BLVD STE 110, FORT WAYNE, IN 46804-4159
(260) 436-4116
(260) 436-1878
Mailing address
7910 W JEFFERSON BLVD STE 110, FORT WAYNE, IN 46804-4159
(260) 436-4116
(260) 436-1878
Taxonomy
Speciality
Code
Description
License number
State
2085R0001X
Radiation Oncology Physician
Primary
01032697A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0573026
—
OH
05
—
100321360
—
IN
05
—
1194726927
—
MI
Enumeration date
08/02/2005
Last updated
06/20/2016
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