Basic Information
| Provider Information | |||||||||
| NPI: | 1104874452 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEVANATHAN | ||||||||
| FirstName: | SRINIVASAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11109 PARKVIEW PLAZA DR # 117 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602666013 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8028 CARNEGIE BLVD. | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468045790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2609697100 | ||||||||
| FaxNumber: | 2609697263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 10/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 01059028A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RS0012X | 01059028A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207RP1001X | 01059028 | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 200481860 | 05 | IN | MEDICAID | P00867128 | 01 | IN | R.R. MEDICARE | OTHER | 000000670561 | 01 | IN | ANTHEM | OTHER |