Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207RC0200X | Critical Care Medicine | 01059028A | IN |
Y | 207RP1001X | Pulmonary Disease | 01059028 | IN |
N | 207RS0012X | Sleep Medicine | 01059028A | IN |
NPI | 1104874452 |
---|---|
Provider Name | Dr. Srinivasan Devanathan |
First Address | Fort Wayne, IN 46845-1701 |
Second Address | Fort Wayne, IN 46804-5790 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/05/2006 |
Last Update Date | 15/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000670561 | ANTHEM (01) | IN |
200481860 | (05) | IN |
H92175 | (02) | IN |
P00867128 | R.R. MEDICARE (01) | IN |