Healthcare Provider Details

I. General information

NPI: 1164493623
Provider Name (Legal Business Name): MANGESH KANVINDE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2006
Last Update Date: 05/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

361 CROSS ROADS BLVD
COLD SPRING KY
41076
US

IV. Provider business mailing address

361 CROSS ROADS BLVD
COLD SPRING KY
41076-2194
US

V. Phone/Fax

Practice location:
  • Phone: 859-474-0374
  • Fax:
Mailing address:
  • Phone: 859-474-0374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number01059611A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number35076521
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME96979
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number39807
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: